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Equipoise
Greene and Loscalzo have published an interesting article on some implications of new research into networks.[1] They start by reviewing the concept of scientific reductionism, which they define as using the tools of another more basic science to explain biological phenomena. But in medical science and practice, reductionism is “often equated with disease as something that can be separated from the sick person and scrutinized with successively finer analytic tools.” This approach has yielded some startling successes, such as control of tuberculosis. But it has also provoked reaction from those in the social sciences, who note “biomedical sciences objectified everything without necessarily improving patient care.” When looking at the Human Genome Project, they note that a straight-forward Mendelian approach to disease—one or a few genes, one disease—accounts for a minority of human diseases. “It is thus important to reconceive biologic and pathobiologic phenomena in terms of complex networks of interacting genes or gene products and layers of environmental modulators…Most biologic systems are clustered, or scale free: a few nodes are highly connected to others, while most are weakly connected to the network. This architecture has some interesting consequences for biologic systems, including facilitation of biochemical diversity at minimal energy cost. Mutations or polymorphisms in weakly connected nodes (genes) account for normal biologic variability and complex illness, whereas those in highly connected genes (hubs) lead to early death of an organism” The authors go on to extrapolate this image into a broader context. “Network science could help us understand human disease at both micro and macro levels. Yet it is limited by decisions about what is included in, and excluded from, the data set it uses…Network analysis can also potentiate an understanding of the social and political contexts within which behaviors or environmental exposures contribute to disease development…In the arc of Western understandings of disease that began with the holism of the sick person and then atomized it into units of pathology, we are attempting a reassembly or reconstruction. The task of putting the patient back together again will be complex, arduous, and time consuming, but it promises a new articulation of the biologic and social sciences that are inextricably linked and essential to the advancement of medicine.” While this paper is undoubtedly focused on “big ideas,” I don’t think it reflects the realities of medical practice, as opposed to medical science. While some physicians may focus only on “the disease the patient has,” most are forced to recognize the importance of “the patient who has the disease.” I also think most physicians are rather open-minded about where the evidence they use comes from—be it from biologic reductionism or social science. We tend to be more interested in whether it helps in daily care of sick people or not. Pragmatism has always been the defining characteristic of medical practice. Of course, “in my experience” is denigrated as a source of wisdom by those who consider themselves “scientists,” but the n=1 experiment also has power. All of this leads to a consideration of equipoise. As defined by David Brooks,[2] this is the ability to weave our multiple “identities” into a balanced whole. He notes the world’s tendency is to label others by a single identity—a monad identity, and some persons do, in fact, allow this single identity to define who they are. “The more vibrant attachments a person has, the more likely she will find some commonality with every other person on earth…The world isn’t only a battlefield of groups; it’s also a World Wide Web of overlapping allegiances…The final step is to practice equipoise…It’s the ability to move gracefully through your identities—to have the passions, blessings and hurts of one balanced by the passions, blessings and hurts of several others. The person with equipoise doesn’t feel attachments less powerfully but weaves several allegiances into a deep symphony.” Perhaps equipoise is what is needed more than anything else as we enter the new year. Rather than “doctors versus administrators,” for instance, we need to see the overlaps. After all, most administrators want good care for patients just like most doctors do. To use the science analogy, if we could make some progress on agreeing where the reductionist approach works better, and where the network approach is more apt, I suspect we could see real improvements in both the quality of care as delivered, and reduce the cost. In this season of the “lion lying down with the lamb,” this is not too much to hope for, but it will take real work on all sides to make it a reality. 26 December 2017 [1] Greene JA, Loscalzo J. Putting the Patient Back Together—Social Medicine, Network Medicine, and the Limits of Reductionism. NEJM 2017;377(25):2493-2499. doi: 10.1056/NEJMs1706744. [2] Brooks D. In Praise of Equipoise. The New York Times, 1 September 2017, p. A23. Accessed that date at https://www.nytimes.com/2017/09/01/opinion/in-praise-of-equipoise.html. |
Further Reading
Communications Messaging is replacing dialogue in clinical practice to the detriment of all. Culture Matters The scandal at the VA shows the importance of choosing performance measures wisely and the need to consider organizational culture in applying standard management techniques. Emotional Intelligence for Physicians How do physicians rate in the domains of emotional intelligence? Empathy Is empathy the value we have tossed out as part of "improving" health care? The One Best Way |