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Editor's Choice

Whither medicine?

BMJ 2006; 333 doi: (Published 07 September 2006) Cite this as: BMJ 2006;333:0-f

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The nuciform sac-the darker side of the moon.

Dear Editor,

I agree that we should take pride in what modern medicine has
achieved but, there is also the other side of the coin that we seem to be
missing! 80% of the world population has no touch with modern medicine,
thanks to the prohibitive cost. The hi-tech stuff is available only to the
rich. This reminds me of the time, exactly a Century ago, when George
Bernard Shaw beautifully showed the tricks of the medical profession
through his characters in his play Doctor’s Dilemma:

“Sir Colenso Ridgeon thinks he has discovered a cure for tuberculosis
through opsonins. Ridgeon has a limited number of vacancies at his medical
Lourdes. He must decide between offering treatment to a decent,
impoverished elderly fellow physician or to an artistically gifted young
scoundrel. The matter is complicated by middle-aged bachelor Ridgeon’s
attraction to the talented cad’s “arrestingly good-looking wife.”

“All professions,remarks one of the play’s doctors, are conspiracies
against the laity. And Shaw, in addition to debunking medical omniscience
and conventional morality, introduces an amusing set of conspirators here.
Harrumphing Sir Patrick Cullen has been around long enough to be dubious
of the variously self-interested medical pontifications of his colleagues.
Gentleman’s physician Sir Ralph Bloomfield Bonington is dangerously
cavalier in his attacks on disease, juggling vaccines willy-nilly. And Sir
Cutler Walpole thinks the cure for everything from TB to toothache is the
removal of the patient’s nuciform sac.” My efforts to locate the nuciform
sac in the human anatomy texts have failed so far! Shaw assembled a motley
medical army which is almost identical to the usual crowd that one meets
today after one hundred years! Through this satire Shaw was able to stop
the cruelty of total colectomies for chronic fatigue syndrome. The medical
profession and their journals could not stop Sir Arbuthnot Lane from his
surgical heroics!

Thomas Lewis, the then Chief of Sloan Kettering in his beautiful
book, The Lives of a Cell, has a good advice for all of us. “Instead of
always emphasizing what we actually know in science, it would be
enormously fruitful to focus alternatively on what we do not know. For it
is here that the wonders lie. To know is the domain that is safe, where
risk taking is no longer necessary. To dwell in it forever is not only to
never advance, it is also to promote a deceptive and false view of
ourselves as knowing more than we do-of being more powerful than we really

Now let us take an impartial audit. 59% of improvement in the health
scene in the west has come from higher standards of living, better
nutrition, control of simple communicable diseases through better
sanitation and education while only 3.4% could be attributed to hi-tech
medicine. The war on cancer is anything but won and the future does not
look good. Our present modalities of treatment of cancer remind us of the
way our ancestors used to brand every disease with red hot iron! Even
there treatment strategies depend more on who you see and what facilities
they have. The only disease mankind has been able to eradicate, small pox,
was achieved through very low tech vaccination system that prevailed in
India from “times out of mind”. Our war against chronic diseases is
anything but started to yield any benefit to the patients. "Doctor-thinks-
you have a disease" treatments and disease inventions through routine
screening are our biggest rice bowls!

The big till movers, the cardiac interventions, is another big story.
"Nortin Hadler of North Carolina at Chapel Hill is urging the U.S. medical
Establishment to rethink its most basic precepts of cardiovascular care.
Bypass surgery in particular, he says, should have been relegated to the
archives 15 years ago. People often believe that having these procedures
fixes the problem, as if a plumber came in and fixed the plumbing with a
new piece of pipe, explains Dr. L. David Hillis, of the University of
Texas Southwestern Medical School. But it fundamentally doesn't fix the
problem. With doctors doing about 400,000 bypass surgeries and 1 million
angioplasties a year in the US alone -- part of a heart-surgery industry
worth an estimated $100 billion a year -- the question of whether these
operations are overused has enormous medical and economic implications,
says Dr. David Waters, chief of cardiology at the University of California
at San Francisco.”

"There is quite a lot of good evidence for symptom relief, says Dr.
Robert Henderson, a cardiologist at Nottingham City Hospital. Critics such
as Hadler, on the other hand, emphasize the risks. Not only is there a 1%
to 2% chance of dying during a bypass operation, there is a high risk of
complications and a 40% chance of cognitive deficits. Recent studies even
raise questions about whether surgery causes the symptom relief. In June
2005, Harvard Medical School associate professor Roger J. Laham reported
on follow-up results of a randomized trial looking at laser surgery to
improve blood flow. Patients who got the surgery had significantly less
pain and improved heart function. But so did patients who had a sham
operation -- the equivalent of a placebo. After 30 months the placebo
effect was still there. Scans and other tests showed physiological gains
in blood flow among only those who thought they had been operated on. A
similar large placebo effect might explain most of the benefits that we've
seen so far with balloon angioplasty and bypass surgery," Laham says.

Similar comparisons can help pinpoint dubious treatments in the past
like the classic case of tonsillectomy. "More recently, Dr. James N.
Weinstein, chair of orthopedic surgery at Dartmouth found that people with
back pain are up to 20 times as likely to have back surgery in some parts
of the country as in others. Yet it's not clear that they do better as a
result. At many hospitals, cardiac units have become major profit
centers. Out of 100 patients who get a drug-coated stent vs. a bare-metal
stent, maybe 10 will avoid a repeat procedure," says Dr. Eric J. Topol,
chief of cardiology at the Cleveland Clinic Foundation. But how many will
wind up with a heart attack or death? We just don't have that nailed down
yet.” David Eddy’s computer model ARCHIMEDES has scientifically debunked
most of our heroic treatment models as useless and might even be
dangerous. This is reflected in IOM audit of US medicine.

To have an impartial audit, Fiona Godlee should invite researchers to
write about our failures as well. We will thus have built a great
Centenary memorial to Sir George Bernard Shaw, through the leader in the
field, BMJ. “Knowledge advances not by repeating known facts, but by
refuting false dogmas” wrote Karl Popper. Let us learn from history as
otherwise we will be cursed to relive history, as warned by Cicero.
Remember Galen in 127 AD proclaimed that the blood gets pumped through the
liver. For nearly 1500 years everyone believed that only to be refuted by
William Harvey in 1628 AD!

Yours ever,

Competing interests:
None declared

Competing interests: No competing interests

09 September 2006
BM Hegde
Retired Vice Chancellor
Mangalore 575004, India