Too much doing and too little thinking in medical science!

Science is facts; just as houses are made of stones, so is science made of facts. But a pile of stones is not a house and a collection of facts is not necessarily science. (Henri Poincaré, mathematician and physicist [1854–1912])

Fragmentation and hyper-specialization dominate both medical research and practice to an increasing extent. Even general practice is under siege as a “holistic” discipline [1]. Very few doctors seem to object. In fact, detailed knowledge about small and esoteric matters gives an air of sophistication and competence which is hard to challenge, not least for busy clinicians with limited research training. But where is medical science currently heading? We want to reflect on this question with reference to a recent, real-life scenario and quotes from three cutting-edge biomedical scientists.

Scenario: During a seminar on Genetics in endocrinology, a researcher presented evidence for an association between elevated testosterone levels in the pregnant woman and an increased risk of pathological conditions in the child-to-be. One of the few attending generalists (LG) commented that similar patterns of deviations have been associated with distress in pregnant women and presumably “toxic” levels of maternal cortisol. Consequently, the generalist asked: “How do you endocrinologists see the whole picture? What links can there be between testosterone's and cortisol's potentials to detrimentally affect fetal neurodevelopment?” The speaker, who acknowledged the question as relevant, chose not to reflect on it. Apparently, his field of expertise was testosterone, not cortisol.

Today's young scientists are systematically stimulated to become mainstream, low-risk “doers”. This means producing so-called original empirical research on the basis of “manageable” hypotheses and delivering before a given deadline. Problems are often identified as “researchable” with reference to mainstream study designs and methodologies. Practical feasibility often comes before clinical relevance when project plans are developed. Only the very brave or very eccentric are likely to hold on to ambitious, complex, and “real-life” research questions in this industrial atmosphere. So who, then, is going to conduct innovative and risky (in the sense of time-consuming, complex, and unpredictable) academic work? And who takes on the challenge to gather, investigate, and integrate existing knowledge across subspecialties and disciplines, and to think: What does all this knowledge mean? What kind of additional knowledge is now needed?

In the near future, we would like to see original and analytic thinking flourish in medicine, with the ambitious aim to contribute to a deeper and more comprehensive theoretical framework for human sickness and health than the biomedical approach currently allows for. A theoretically sound foundation is warranted which integrates knowledge about human experience expressed as suffering with knowledge about human physiology expressed in function. This integrated knowledge must accord with the unique conditions of human being-in-the-world, as these are formulated in existential and phenomenological philosophy [2]. A fascinating field of converging knowledge has recently emerged, with the potential to move biomedical reasoning in a sound direction. It comprises various disciplines – psychology, neurology, endocrinology, and immunology – and is presently named by various shorthands such as psycho-neuro-immunology. Studies in this field have for instance documented the personal interpretation (appraisal) of an experience to be decisive in terms of how this event will affect the individual in both a short- and a long-term perspective. This finding invalidates the traditional methodological assumption that events categorized as “the same” (such as a divorce or the death of spouse) will affect the studied subjects in the “same” way. But it is not the event as such, but the experiencing person who interprets the event in light of previous experience who will ultimately determine its individual impact [3].

What does the mainstream medical establishment currently do with such groundbreaking and theoretically challenging findings? Very little! Traditional data gathering goes on as usual. This brings to mind a quote from the 1915 Nobel laureate in physics William Bragg. In the middle of one of physics’ major paradigm shifts he is supposed to have said:

The important thing in science is not so much to obtain new facts as to discover new ways of thinking about them.

Medicine now needs new ways of thinking about all the data which are already there. The scientific medical literature contains numerous, independent calls for “more emphasis on thinking and less emphasis on new data”. Quotes from three highly distinguished researchers in different disciplines illustrate our point. The first is from a leading scientist in the field of neuroscience, Professor of Biology and brain researcher Steven Rose [4]:

Many neuroscientists [presently] argue that there is a greater priority than acquiring new data. The world-wide effort being poured into the neurosciences is producing an indigestible mass of facts at all levels…. [But] behind all these potentially laudable moves forward there lies a vacuum. Empiricism is not enough. Simply, we currently lack a theoretical framework within which such mountains of data can be accommodated. We are, it seems to me, still trapped within the mechanistic reductionist mind-set within which our science has been formed. Imprisoned as we are, we cannot find ways to think coherently in multiple levels and dimensions, to incorporate the time line and dynamics of living processes into our understanding of molecules, cells and systems.

A similar voice can be heard from cardiovascular genetics. Ali J. Marian recently spoke about the currently identified 12 million Single Nucleotide Polymorphisms (SNP) resulting from genetic research and states that there is a need for less fragmentation and more holistic thinking if we want to understand the genome [5]:

A complete paradigm-shift from the current SNP-centric to a more comprehensive genome-centric approach is necessary to capture the full potential of the genome.

Finally, immunologist and former editor-in-chief of the journal Graft, Charles Orosz, recently wrote an editorial in which he said [6]:

More to the point, how can immunologists fill the void between their satisfying accumulation of immunologic facts and their unsatisfactory understanding of immune function?

Why are these quotes from hyper-specialized scientists of particular interest to general practitioners? It strikes us that general practice, neuroscience, genetics, and immunology are currently facing some fundamentally similar theoretical challenges. These disciplines all struggle to make sense of an immense “whole” which ranges from “the human mind” (neuroscience) to “this individual in front of me” (general practice). The mind, the genome, the immune system, and the person are all far beyond our scientific comprehension – but we definitely know that they are more than the sum of their biological sub-units.

In order for competent and innovative knowledge exploration to take place in parallel with conventional data gathering, it is important that creative and skilled reflection will count as original research in medical academe. Competent analytical thinking should be considered just as important and valuable to medicine as competent doing of traditional, empirical research. Here lies a major challenge for the medical academy in general and for medical journals, such as the Scandinavian Journal of Primary Health Care, in particular [7].