0895-4356/90 $3.00 + 0.00 Copyright 0 1990 Pergamod Press plc
J Clin Epidemiol Vol. 43, No. 9, pp. 1001-1003, 1990 Printed in Great Britain. All rights reserved
Second Thoughts INTIMATIONS
OF UNCERTAINTY MEDICINE
IN THE PRACTICE
OF
JOSEPH HERMAN* Department
of Family Medicine, Division of Health in the Community, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
(Received6 July 1989; receivedfor publication 23 January 1990)
Just over six decades ago Heisenberg enunciated the Principle of Uncertainty that bears his name. It stated that the momentum and velocity of a sub-atomic particle cannot be determined with any desired degree of accuracy and it suggested that the very act of observation caused a change in the particle’s location. Thus, a discontinuity was introduced into the Newtonian chain of causality, or so it seemed, as the Principle was subjected to a wide variety of interpretations, misinterpretations and reinterpretations. The word “uncertainty” shaded almost imperceptibly into “indeterminacy”, with the implication that some unique quality of electrons and positrons was under discussion, a kind of “free will” enabling them to evade the laws of nature. It was Bertrand Russell who finally pointed out that the stricture was on our own powers of observation [ 11. Man has a penchant for being able to think rigorously about the unthinkable. Even in mathematics, which has been called the language of science, the mind plays such seeming tricks. For exampie, if the curve y = eXbe rotated about the x-axis, a surface is developed enclosing a finite volume but of infinite extent, one that can, as it were, be filled with paint but not painted. As absurd as this state of affairs may appear, no one would propose that a result contrary to everyday experience should lead us to discard the integral calculus. *All correspondence should be addressed to: Joseph Herman M.D., 42 Harav Uzziel Street Bayit V’gan 96424, Jerusalem, Israel.
Blois has spoken of a hierarchy of the sciences, with those at the lowest level, such as physics, containing no more than what can be expressed mathematically, while those at the highest lend themselves only to lengthy, incomplete and qualitative characterization [2]. Obviously medicine, insofar as it is a science at all, belongs to the latter category. Blois makes no mention, however, of what Man is beyond his neuropsychological properties and does not consider the additional variability introduced by his having will, feeling, sensibilities and moral being [3]. He denies that an uncertainty principle underlies the poor utility of mathematics for the higher sciences, stating that the quandary is not the basic unobtainability of data but rather our own limitations as human agents who have only finite time and energy at our disposal [2]. On the other hand, Minuchin and Fishman, who represent family therapy, one of the highest level sciences, believe that there is inescapable uncertainty in its practice [4], emanating from the interaction between observer and observed and bringing us back full cycle to sub-atomic particles! It has been said that the number of grains of sand along the shore at Coney Island is finite though difficult to count with our present technology [5]. The same is true for the traits, characteristics and behaviors of even a single individual, to say nothing of the entire human race together with the cultural, political and economic factors impinging on it. What, then, is the difference between something that is infinite and something that is too large to measure with
1001
1002
Second Thoughts
the time and energy available? Practically speaking, the two situations are identical, but in theory the first tells us that further effort is futile while the second says, in effect, “It is not your duty to complete the task, but you are not free to desist from it” [6]. The circle cannot be squared, but good approximations can be made; fifth degree algebraic equations are not solvable by radicals, but values for x that will yield a result close to zero can be found. Thus, we should not despair of being able to express our knowledge of a patient in a meaningful way although we should disabuse ourselves of the hope that probability theory will be able to do the job for us. The gap between statistical prediction and individual fate has been recognized and colorfully called “Why him?’ [7]. There are many intimations of uncertainty between physician and patient, in a sense parameters of what human beings are, that are difficult to quantify but nonetheless have an impact on health: past experience, present circumstances, culture, the family of origin, the health care system within which the relationship is sustained, the macro-social environment and so on. If one attempts to categorize and generalize, as the hard sciences do, then one is faced with a totality of different genetic make-ups approximately equal to 4 billion less one half the number of identical twins throughout the world, a daunting figure indeed, and only on the threshold of the permutations and combinations of which it admits. These, in turn, permute and combine with the above-mentioned parameters as well as with the more transient variants of everyday interaction to yield an integer of staggering, though still not infinite, dimension. Let us oversimplify the matter somewhat. A patient walks through the door of my office and I make the “soft” observation that he has not shaved, is disheveled and looks both down at the heels and down in the mouth. Then I take a “hard” measurement and note a blood pressure of 120/80. I can also perform a venipuncture and know, within a few minutes, that his glucose level is 107 mg/dl. Now, hard values vary no less than soft signs along the axes of the human continuum which may be thought of as encompassing chiefly sensation (hunger, pain, itch, blurred vision), emotion (anger, compassion, joy) and time. Thus, not only the way my patient looks, but also his blood pressure and plasma glucose concentrations will fluctuate according to the way I behave, itself a function of what may have happened to me on the way to
work. This was clearly demonstrated by the variability in blood flow through Tom’s externalized gastric mucosa in the experiments of Wolf and Wolff [8]. If it were not so, then there would be no need of the glucose clamp technique for much of our laboratory work on different states of glycemia [9]. We see, then, that what brings us closest to a rigorous demonstration of an uncertainty principle in scientific medicine is the introduction of the variable of time. I cannot locate my patient in his continuum because, when I have done with my observations and measurements, he is no longer “there” but somewhere else, due in part to my effect on him. Some recent work has complicated matters still further by suggesting that the patient, operating as it were through his doctor, may influence the results of treatment. For example, by means of an educational intervention imparting a sense of control during his interview with a physician he can be shown to function better in the face of continued ulcer pain than would another person, equally satisfied with the encounter but unschooled in it [lo]. Furthermore, the long-term outcome of headache in primary care seems to be most closely associated with a sense of satisfaction at the end of the first consultation and less so with the making of a specific diagnosis [I 11. This astounding piece of information confirms brilliantly what Balint posited over four decades ago when he referred to the patient’s “offers” in the organic realm as often being metaphors for environmental “problems”. He pointed to the dire consequences of allowing the patient to settle down to a lifetime within the confines of illness as a result of having the anatomic basis for his offer “ruled out”. He even went so far as to predict that, faced with a somatically fixated physician, the patient might grow organs in parts of his body where there are none [12]! Studies that have related persistent, unrelieved stress to immunological breakdown [ 131suggest a need to look to our humanistic guns and, in that light, the following antinomy, though purely speculative, is interesting. Suppose that by listening carefully for historical cues and performing a competent rectal examination I diagnose a very early carcinoma of the rectum in a young man. Am I not entitled to be proud of my clinical acumen and to credit myself with having saved his life? But, on the other hand, what if he began to incubate his carcinoma some years ago, after a failed first interview when I did not elicit details about
SecondThoughts unhappiness at home? Shouldn’t I castigate myself for his turning a problem into a disease and my not turning it back into a problem? [14]. Kant referred to antinomies as the unavoidable contradictions to pure reasoning which human limitations introduce [15]. The fourth of Karl Jaspers’ Laws of Understanding states that “Opposites are equally meaningful”, implying that opposing interpretations can be based on the same evidence [16]. Oswald Spengler showed that the science of each civilization, like art and religion, has a style of its own, something that makes truth both temporary and relative [17]. That it has esthetic cravings too is shown by our frequent use of such expressions as “an elegant proof “, or “a beautifully conceived demonstration”. Finally, despite the contention that a scientific question is one that can be answered by a suitably designed experiment, even if the technology for its execution is not yet available [18], a definition that excludes discussion of God, science requires faith. Einstein put it well when he said: “I cannot believe that God plays dice with the world” [19]. In order to think scientifically, we must hold fast to the belief that the universe is comprehensible. The Uncertainty Principle and the antinomies of everyday practice should not lead us to fashionable despair. The former imbues what we do with a constant sense of adventure, while the latter affords many more therapeutic options than would be available were we to adhere to a reductionistic approach. The pressure to intervene, on the other hand, may be seen in proper perspective if we recall the historic task of medicine which was to provide explanation and reassurance to healthy members of society, frightened by changes they saw in an individual’s appearance or functioning [20]. By this same token, the enormous curative potential we have accumulated over the course of the 20th century appears as an accident of history. As such, it may well be the source of the malaise that besets us. Rigorous thinking belongs, for the most part, in the province of the philosopher and the mathematician, whereas the hallmark of scientific activity is a critical attitude [16]. This is the thrust of many of the papers that were read at a symposium held in 1988 and charged with redefining medicine’s task. It was sub-titled Dialogue at Wickenburg and its participants did not eschew the insights of art as a way to a
1003
better understanding of the patient. Since dialogue is what we are really about, a much older one that took place on the parapets of Elsinore still has a message for our beleaguered calling: Horatio 0 day and night, but this is wondrous strange!
And therefore as a stranger give it welcome. There are more things in heaven and earth, Horatio than are dreamt of in your philosophy.
REFERENCES 1. Newman JR. The World of Mathematics. New York: Simon and Schuster; 1956: 1047-1049. 2. Blois MS. Medicine and the nature of vertical reasoning. N Eagl J Med 1988; 318: 847-851. 3. Sacks 0. fhe Man Who Mistook His Wife for a Hat and Other Clinical Tales. New York: Harner & Row: 1985: 34. 4. Minuchin S, Fishman HC. Family Therapy Techniques. Cambridge: Harvard University Press; 1981: 80. 5. Newman JR. The World of Mathematics. New York: Simon and Schuster; 1956: 2007. 6. Ethics of the Fathers. New York: Hebrew Publishing Company; 1962: 36. I. Metcalfe D. Book reviews. Fam Pratt 1989; 6: 74. 8. Samson Wright’s Applied Physiology, 12th edn. London: Oxford University Press; 1971: 407. 9. DeFronzo RA, Tobin JD, Andres R. Glucose clamp technique: a method for quantifying insulin secretion and resistance. Am J Physiol 1979; 237: E214-E223. 10. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985: 102: 520-528. 11. The Headache Study Group of the University of Western Ontario. Predictors of outcome in headache patients presenting to family physicians-a one year prospective study. Headache 1986; 26: 285-294. 12. Balint M. The Doctor, His Patient and the Illness. London: Pitman Medical; 1973. 13. Rogers MP, Dubey D, Reich P. The influence of the psyche and the brain in immunity and disease susceptibility: a critical review. Psychosom Med 1979; 41: 147. 14. Stephens GG. Reflections of a post-Flexnerian physician. In: White KL, Ed. The Task of Medicine. Menlo Park: The Henry J Kaiser Family Foundation; 1988: 172-189. 15. Webster’s New Twentieth Century Dictionary, 2nd edn. U.S.A.: Collins World; 1978. 16. Schwartz MA, Wiggins OP. Scientific and humanistic medicine: a theory of clinical methods. In: White KL, Ed. The Task of Medicine. Menlo Park: The Henry J. Kaiser Family Foundation; 1988: 137-l 7 1. 17. Spengler 0. The Decline of the West. New York: Alfred A. Knopf; 1947. 18. Reichenbach H. Experience and Prediction. Chicago: The University of Chicago Press; 1938. 19. Frank P. Einstein: His Life and Times. New York: Alfred A. Knopf; 1947. 20. Fabrega H, Jr. The position of psychiatry in the understanding of human disease. Arch Cen Psychlat 1975; 32: 1500-1512.
J Clin Epidemiol Vol. 43, No. 9, pp. 1001-1003, 1990 Printed in Great Britain. All rights reserved
Second Thoughts INTIMATIONS
OF UNCERTAINTY MEDICINE
IN THE PRACTICE
OF
JOSEPH HERMAN* Department
of Family Medicine, Division of Health in the Community, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
(Received6 July 1989; receivedfor publication 23 January 1990)
Just over six decades ago Heisenberg enunciated the Principle of Uncertainty that bears his name. It stated that the momentum and velocity of a sub-atomic particle cannot be determined with any desired degree of accuracy and it suggested that the very act of observation caused a change in the particle’s location. Thus, a discontinuity was introduced into the Newtonian chain of causality, or so it seemed, as the Principle was subjected to a wide variety of interpretations, misinterpretations and reinterpretations. The word “uncertainty” shaded almost imperceptibly into “indeterminacy”, with the implication that some unique quality of electrons and positrons was under discussion, a kind of “free will” enabling them to evade the laws of nature. It was Bertrand Russell who finally pointed out that the stricture was on our own powers of observation [ 11. Man has a penchant for being able to think rigorously about the unthinkable. Even in mathematics, which has been called the language of science, the mind plays such seeming tricks. For exampie, if the curve y = eXbe rotated about the x-axis, a surface is developed enclosing a finite volume but of infinite extent, one that can, as it were, be filled with paint but not painted. As absurd as this state of affairs may appear, no one would propose that a result contrary to everyday experience should lead us to discard the integral calculus. *All correspondence should be addressed to: Joseph Herman M.D., 42 Harav Uzziel Street Bayit V’gan 96424, Jerusalem, Israel.
Blois has spoken of a hierarchy of the sciences, with those at the lowest level, such as physics, containing no more than what can be expressed mathematically, while those at the highest lend themselves only to lengthy, incomplete and qualitative characterization [2]. Obviously medicine, insofar as it is a science at all, belongs to the latter category. Blois makes no mention, however, of what Man is beyond his neuropsychological properties and does not consider the additional variability introduced by his having will, feeling, sensibilities and moral being [3]. He denies that an uncertainty principle underlies the poor utility of mathematics for the higher sciences, stating that the quandary is not the basic unobtainability of data but rather our own limitations as human agents who have only finite time and energy at our disposal [2]. On the other hand, Minuchin and Fishman, who represent family therapy, one of the highest level sciences, believe that there is inescapable uncertainty in its practice [4], emanating from the interaction between observer and observed and bringing us back full cycle to sub-atomic particles! It has been said that the number of grains of sand along the shore at Coney Island is finite though difficult to count with our present technology [5]. The same is true for the traits, characteristics and behaviors of even a single individual, to say nothing of the entire human race together with the cultural, political and economic factors impinging on it. What, then, is the difference between something that is infinite and something that is too large to measure with
1001
1002
Second Thoughts
the time and energy available? Practically speaking, the two situations are identical, but in theory the first tells us that further effort is futile while the second says, in effect, “It is not your duty to complete the task, but you are not free to desist from it” [6]. The circle cannot be squared, but good approximations can be made; fifth degree algebraic equations are not solvable by radicals, but values for x that will yield a result close to zero can be found. Thus, we should not despair of being able to express our knowledge of a patient in a meaningful way although we should disabuse ourselves of the hope that probability theory will be able to do the job for us. The gap between statistical prediction and individual fate has been recognized and colorfully called “Why him?’ [7]. There are many intimations of uncertainty between physician and patient, in a sense parameters of what human beings are, that are difficult to quantify but nonetheless have an impact on health: past experience, present circumstances, culture, the family of origin, the health care system within which the relationship is sustained, the macro-social environment and so on. If one attempts to categorize and generalize, as the hard sciences do, then one is faced with a totality of different genetic make-ups approximately equal to 4 billion less one half the number of identical twins throughout the world, a daunting figure indeed, and only on the threshold of the permutations and combinations of which it admits. These, in turn, permute and combine with the above-mentioned parameters as well as with the more transient variants of everyday interaction to yield an integer of staggering, though still not infinite, dimension. Let us oversimplify the matter somewhat. A patient walks through the door of my office and I make the “soft” observation that he has not shaved, is disheveled and looks both down at the heels and down in the mouth. Then I take a “hard” measurement and note a blood pressure of 120/80. I can also perform a venipuncture and know, within a few minutes, that his glucose level is 107 mg/dl. Now, hard values vary no less than soft signs along the axes of the human continuum which may be thought of as encompassing chiefly sensation (hunger, pain, itch, blurred vision), emotion (anger, compassion, joy) and time. Thus, not only the way my patient looks, but also his blood pressure and plasma glucose concentrations will fluctuate according to the way I behave, itself a function of what may have happened to me on the way to
work. This was clearly demonstrated by the variability in blood flow through Tom’s externalized gastric mucosa in the experiments of Wolf and Wolff [8]. If it were not so, then there would be no need of the glucose clamp technique for much of our laboratory work on different states of glycemia [9]. We see, then, that what brings us closest to a rigorous demonstration of an uncertainty principle in scientific medicine is the introduction of the variable of time. I cannot locate my patient in his continuum because, when I have done with my observations and measurements, he is no longer “there” but somewhere else, due in part to my effect on him. Some recent work has complicated matters still further by suggesting that the patient, operating as it were through his doctor, may influence the results of treatment. For example, by means of an educational intervention imparting a sense of control during his interview with a physician he can be shown to function better in the face of continued ulcer pain than would another person, equally satisfied with the encounter but unschooled in it [lo]. Furthermore, the long-term outcome of headache in primary care seems to be most closely associated with a sense of satisfaction at the end of the first consultation and less so with the making of a specific diagnosis [I 11. This astounding piece of information confirms brilliantly what Balint posited over four decades ago when he referred to the patient’s “offers” in the organic realm as often being metaphors for environmental “problems”. He pointed to the dire consequences of allowing the patient to settle down to a lifetime within the confines of illness as a result of having the anatomic basis for his offer “ruled out”. He even went so far as to predict that, faced with a somatically fixated physician, the patient might grow organs in parts of his body where there are none [12]! Studies that have related persistent, unrelieved stress to immunological breakdown [ 131suggest a need to look to our humanistic guns and, in that light, the following antinomy, though purely speculative, is interesting. Suppose that by listening carefully for historical cues and performing a competent rectal examination I diagnose a very early carcinoma of the rectum in a young man. Am I not entitled to be proud of my clinical acumen and to credit myself with having saved his life? But, on the other hand, what if he began to incubate his carcinoma some years ago, after a failed first interview when I did not elicit details about
SecondThoughts unhappiness at home? Shouldn’t I castigate myself for his turning a problem into a disease and my not turning it back into a problem? [14]. Kant referred to antinomies as the unavoidable contradictions to pure reasoning which human limitations introduce [15]. The fourth of Karl Jaspers’ Laws of Understanding states that “Opposites are equally meaningful”, implying that opposing interpretations can be based on the same evidence [16]. Oswald Spengler showed that the science of each civilization, like art and religion, has a style of its own, something that makes truth both temporary and relative [17]. That it has esthetic cravings too is shown by our frequent use of such expressions as “an elegant proof “, or “a beautifully conceived demonstration”. Finally, despite the contention that a scientific question is one that can be answered by a suitably designed experiment, even if the technology for its execution is not yet available [18], a definition that excludes discussion of God, science requires faith. Einstein put it well when he said: “I cannot believe that God plays dice with the world” [19]. In order to think scientifically, we must hold fast to the belief that the universe is comprehensible. The Uncertainty Principle and the antinomies of everyday practice should not lead us to fashionable despair. The former imbues what we do with a constant sense of adventure, while the latter affords many more therapeutic options than would be available were we to adhere to a reductionistic approach. The pressure to intervene, on the other hand, may be seen in proper perspective if we recall the historic task of medicine which was to provide explanation and reassurance to healthy members of society, frightened by changes they saw in an individual’s appearance or functioning [20]. By this same token, the enormous curative potential we have accumulated over the course of the 20th century appears as an accident of history. As such, it may well be the source of the malaise that besets us. Rigorous thinking belongs, for the most part, in the province of the philosopher and the mathematician, whereas the hallmark of scientific activity is a critical attitude [16]. This is the thrust of many of the papers that were read at a symposium held in 1988 and charged with redefining medicine’s task. It was sub-titled Dialogue at Wickenburg and its participants did not eschew the insights of art as a way to a
1003
better understanding of the patient. Since dialogue is what we are really about, a much older one that took place on the parapets of Elsinore still has a message for our beleaguered calling: Horatio 0 day and night, but this is wondrous strange!
And therefore as a stranger give it welcome. There are more things in heaven and earth, Horatio than are dreamt of in your philosophy.
REFERENCES 1. Newman JR. The World of Mathematics. New York: Simon and Schuster; 1956: 1047-1049. 2. Blois MS. Medicine and the nature of vertical reasoning. N Eagl J Med 1988; 318: 847-851. 3. Sacks 0. fhe Man Who Mistook His Wife for a Hat and Other Clinical Tales. New York: Harner & Row: 1985: 34. 4. Minuchin S, Fishman HC. Family Therapy Techniques. Cambridge: Harvard University Press; 1981: 80. 5. Newman JR. The World of Mathematics. New York: Simon and Schuster; 1956: 2007. 6. Ethics of the Fathers. New York: Hebrew Publishing Company; 1962: 36. I. Metcalfe D. Book reviews. Fam Pratt 1989; 6: 74. 8. Samson Wright’s Applied Physiology, 12th edn. London: Oxford University Press; 1971: 407. 9. DeFronzo RA, Tobin JD, Andres R. Glucose clamp technique: a method for quantifying insulin secretion and resistance. Am J Physiol 1979; 237: E214-E223. 10. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985: 102: 520-528. 11. The Headache Study Group of the University of Western Ontario. Predictors of outcome in headache patients presenting to family physicians-a one year prospective study. Headache 1986; 26: 285-294. 12. Balint M. The Doctor, His Patient and the Illness. London: Pitman Medical; 1973. 13. Rogers MP, Dubey D, Reich P. The influence of the psyche and the brain in immunity and disease susceptibility: a critical review. Psychosom Med 1979; 41: 147. 14. Stephens GG. Reflections of a post-Flexnerian physician. In: White KL, Ed. The Task of Medicine. Menlo Park: The Henry J Kaiser Family Foundation; 1988: 172-189. 15. Webster’s New Twentieth Century Dictionary, 2nd edn. U.S.A.: Collins World; 1978. 16. Schwartz MA, Wiggins OP. Scientific and humanistic medicine: a theory of clinical methods. In: White KL, Ed. The Task of Medicine. Menlo Park: The Henry J. Kaiser Family Foundation; 1988: 137-l 7 1. 17. Spengler 0. The Decline of the West. New York: Alfred A. Knopf; 1947. 18. Reichenbach H. Experience and Prediction. Chicago: The University of Chicago Press; 1938. 19. Frank P. Einstein: His Life and Times. New York: Alfred A. Knopf; 1947. 20. Fabrega H, Jr. The position of psychiatry in the understanding of human disease. Arch Cen Psychlat 1975; 32: 1500-1512.
