As I wade through the therapy literature these days or
speak to students at my workshops, I often see a trend toward methods of
management that do not include an understanding of physiologic processes
familiar to me. I often wonder what I might have missed in school that would
help me understand this, but, lately, I’ve come to understand that I hadn’t
really missed anything, I just wasn’t seeing things from the same perspective.
As it turns out, two things, empiricism and postmodern thought
have overwhelmed therapy.
The former is defined as “a theory that all knowledge
originates in experience” and “a former school of medical practice founded
on experience without the aid of science or theory.” To be empirical is not
inherently a bad thing, and, in fact, is a necessary part of clinical practice.
The danger lies in using empiricism while forgetting that what we can experience
and observe does not represent the whole of any phenomenon. The “deep model”
of the physical world includes the essentially invisible though well understood
chemical alterations necessary for things like nerve conduction. Reducing this
process to its essential characteristics is not easy, but it has led to every
advance of care that I can think of.
Consider this from Higher Superstition: T he Academic
Left and its Quarrels with Science by Gross and Levitt (The Johns
Hopkins University Press 1994): Even the simplest organism is an almost
unimaginably complex system, whose fundamental chemical and physical processes
reflect a heritage of several billion years of trial, error and modification.
Yet a disease can, although certainly does not always, arise from a single,
simple molecular difference buried deep within the continuous, labyrinthine
reaction system that is the chemistry of life.
Without a deep model to guide us, a model based upon years of careful scientific scrutiny, empiricism alone will often mislead and confuse us. It is obvious that those practicing “myofascial release” assign characteristics to the connective tissue that we know it doesn’t possess. When I say “we” I mean those of us who understand the deep model of collagen that includes its molecular structure.
from Higher Superstition: If,
as seems obvious, scientific and technical issues will become increasingly and
urgently relevant to public policy in the decades ahead, how well will such
matters be debated in this country? Obviously, we cannot hold high hopes. The
historic record of American education in making the general public conversant
with basic science has always been poor, except for a brief flurry of serious
effort in the post-Sputnik era. Superstition, whether about astrology, ancient
astronauts, or alien abductions, has always had easy and profitable going.
Fringe medicine and outright quackery, long endemic in American culture, have
taken on a new and ominous vigor, thanks in part to the dizzily rising costs and
increasing impersonality of health care. The contrast between the incomparable
virtuosity of professional American science and the general public disregard of
scientific substance, whether from complacency or hostility, grows ever more
pronounced. It is one of the great social paradoxes of history.
agree. And it doesn’t seem to me that this trend is heading in the hoped for
direction. At least the direction I’m hoping for.
and Leibovici’s essay from the British
Medical Journal is,
well, thoroughly British, and therefore a bit difficult to follow. At least,
from the perspective of someone educated at Ohio State. However, as I read it
repeatedly I came to feel that its message was extremely important. I’d like
to quote from it a bit more and add some commentary.
Two conceptual frames are relevant to the present
discussion. One (the empiricalsocial construct) is ill equipped to deal
with the clamour of alternative medicine. Like the warbler, it ignores the absence of vital cues because of
the loud signal. The other frame (the “deep model” empirical one) has
deficiencies but is better protected against a loud false signal. Even firm
empiricists, should use some of the protective mechanisms offered by the second
frame. Both frames are defined by several assumptions.
This reference to the warbler concerns the authors equating the loud voice
of alternative medicine to the cuckoo chick deposited in the warbler’s nest.
The mother warbler (purely an empiricist) is unable to recognize the essential
difference between the loud chick and her own, and thus feeds the noisy one to
the detriment of her family.
The authors then explain the difference between what they call two “conceptual
frames.” The first is the combination of empiricism and social
construct. Its tenants are as follows:
is a social construct
of medicine are defined in social terms
firmly believe only in empirical proof
origin of hypotheses does not matter
mission is (and always was) mainly to alleviate suffering
Empirical proof (in
the world of alternative medicine) is so powerful that we really do not care
about the origin of the ideas we examine. The opposite is true: practices or
hypotheses from everywhere are welcomed to be tested. It fits with our
self-image of open mindedness and fairness. When the boundaries of medicine are
shifting (and they shift because of social and political forces, by definition
and belief) we will be able to use our empirical methodology to test what should
or should not be adapted from the practices that are straddling the border now.
The notion that medicine and, in
fact, science itself is dominated by political and social forces is at the core
of postmodernism. For more on this see my essay, What
Went Wrong: Postmodern Thought and
Physical Therapy Practice. The combination of empiricism alone with this
is, in my opinion, a disaster. Beilinson and Leibovici sum up the
alternative community’s attitude in this way: A
combination of oldtime patriarchalism and “scientific” hubris spawned a
hardhearted and conceited breed in medicine. A bit of competition will do no
But when empiricism is
combined with a deep model consistent with physical law and capable of
passing the tests necessary to qualify it as a scientific theory (a higher
standard than is commonly appreciated), it gains a power to help others and grow
closer to the truth as time passes.
The tenants of this second frame are:
scientific method changed the practice of medicine
medicine consists of empirical testing and a deep model
Ø The deep model is essential for choosing hypotheses and learning from failures
medicine does not contradict compassionate and emphatic practice of medicine
Without a reasonable deep model in place we have no way
of assessing failure or success. This leads quite naturally toward forms of
intervention that “might” help, or, at best, “can’t hurt.” The charge
that those of us unwilling to accept methods that have no rational explanation
for their supposed effect are in some way heartless or less “spiritual” than
alternative practitioners has always struck me as insulting and unfounded. Much
could be said about practitioners who charge sick and vulnerable people for
senseless care, but I’ll save that for another time.
Beilinson and Leibovici are pretty clear in their next
(Alternative practitioners say) embrace
empiricism, of course. In the long run, it is the only way to gain the
legitimacy that you seek. But don't bother with “deep models.” Deep models
are for snobs, oppressors, and wishful thinkers. The flat earth, phlogiston,
bleeding, cupping, oppression of women, the Aryan Race—what are these but
(But) The core of scientific medicine is not
empirical testing alone. Empirical proof (elicited using the best methodology)
is very important. Standing alone, however, empirical proof might (and has)
failed us. By definition, it is not protected from a small chance of error. Even
with the best methodology, it is not easily guarded from inadvertent
introduction of bias and from fraud. The building and falsification of bold
hypotheses is at the core of the scientific method. However, there are
hypotheses that cannot be accommodated even at the fringes: that livers of
sacrificial beasts will predict the future; that a substance that causes
complaints similar to the ones observed in a patient will, if diluted to an
infinitesimal concentration, cure them.
A deep model is necessary to choose the hypotheses
we are going to test. Resources are limited. The moment we give up on the model,
we should test everything. How do we choose what to test? There are thousands of
practices, with a multitude of variations. The signals of the cuckoo chick
ensure that it gets well fed by the reed warbler parents is easy to show that a
way chosen from the framework of the “social construct” and does not use a
deep model will soon encounter paradoxes and contradictions.
Reexamining the deep model is the only way to
use the failure of a trial or an experiment to move on. Failure should prompt a
scrutiny of the model (the experiment was correct: how should we change the
model, and which further experimentation will test it?); or a critical look at
the experiment. After each unsuccessful trial in acupuncture there comes a
flurry of letters saying that the study failed because the traditional method
was not used, or that it was used; that it failed because needles were inserted
too deep, or not deep enough, or twirled once too many times. We have no way of
choosing from these explanations because we have no idea of how the treatment is
supposed to work. If we have no idea, we must try all the alternatives.
Scientific medicine was successful because it combined empirical
proof with a deep model. This combination guards it, to a great extent, against
chance, bias, and fraud. We will accept an empirical proof if it fits (even at
the far, nebulous margins) the model of the physical world that we use. The
model applies to the whole of the physical world, including our bodies. This
model changes. A scientist can be defined a person who looks for explanations at
the far fringes of the deep model and brings these fringes to the centre.
but I suppose you get the idea. The absence of a deep model that can be verified
as reasonable without resorting to faith, metaphysics, religious or
quasi-religious belief systems will, it seems, always separate alternative
medicine from the scientific.
I can see no way of reconciling the two as long as this is the case.