Wherefore medical history

by danmalleck

Before I begin, a little Shakespeare tutorial. When Juliet says “Wherefore art thou Romeo?” she’s not asking “where are you?” but “why are you?” In other words, “why are you a Montague?” Her concern was, of course, that he was the child of her family’s arch enemies.

I say that because I’m being snooty humanities guy, and using clever word structures to suggest a depth of understanding. It may be a ruse to seem deep.  Although I do think I stopped trying sometime in second year undergrad, since, contrary to the messages of 1980s high school films, depth was not getting me a girlfriend.

Ok, that’s way more information than I intended to give here.  Let’s move on.

The question of the day is: what use is medical history.

I was talking about this recently with some colleagues who were asking me  what value can medical history provide to health professions.  I was a little preoccupied at the time, and gave a rushed answer.  The even more rushed answer is “plenty.”  But time did not permit me to get into it in more depth.

There has been a big push for medical humanities to be added to medical training recently. The Canadian Medical Association Journal (CMAJ) had an article a few years ago asking why Canadian med schools lag behind the US in this innovation.  The CMJ (which sounds deceptively like the CMAJ but is actually the Croatian Medical Journal) had a great issue on the implementation of medical humanities, mostly focused on initiatives in Eastern Europe. Indeed, there is actually a Journal of Medical Humanities, too.

The evidence generally points to the development of what are often (inappropriately, to me) called “soft skills”: interpersonal interaction, sensitivity to patient needs, awareness of the broader social and cultural issues affecting a patient, etc.  This all goes under the “quality of care” or “professional acumen” or “professional competencies” label. It’s important, affects patients directly, and is certainly not “soft” in its outcome.

I did not talk about that stuff.  I had read a lot of that material, and could have gone on at length, but I wanted to talk about something else, something closer to my research and experience.

Medical history, as medical historian and hematologist Jacalyn Duffin has noted, has the potential to teach health practitioners the value of life-long learning and healthy skepticism. That is, history shows us that we exist on a continuum between the past and future, and that all of our knowledge, techniques, innovations, and assumptions about health are driven by our social and cultural values, economics, politics, and processes that have gone before.  Rather than see what we do as “true” and what people did in the past as “wrong,” rather than looking at the past and saying “how could they have been so stupid?”, medical history encourages us to see that what we believe is a product of our current reality, and that this may change. No, this will change.

The example I often provide to students is the double-blind, placebo-controlled trial (DBPCT). This is considered the “gold standard” of health research. Basically, it emerged from pharmaceutical assays.  You get a bunch of people.  Give half of them a new drug, and half of them a sugar pill. That is the “placebo control.” But it gets better. You make sure the people who are administering the drug, and the people receiving the drug, do not know whether they’re giving/getting the real pharmaceutical or the placebo. that is the double blinded.

The results are considered to be air tight proof of a substance’s effectiveness.

This seems perfectly reasonable, and is to us. as long as you believe the assumptions behind this process.

Assumption 1:  All bodies function basically the same.  This is the foundation upon which modern “western” medicine is based. It underpins the way medicine operates.  If all bodies were not essentially the same, we would need to find unique treatments for each person.  That is time-consuming, and undermines a particular way of doing science.  It introduces subjectivity into a system that strives for evidence-based objectivity.  It is also both a relatively new idea (since subjective interpretation of individual patient conditions was a hallmark of medicine until the early nineteenth century) and also based upon seventeenth century mechanistic physics that has been mostly overturned by modern quantum and string theory physics.

The problem with this assumption is that it is pretty easy to contradict.  The very existence of the idea of a placebo, some kind of unexplainable effect that means sometimes people who think they’re getting a drug actually get better even if they’re not getting the drug, undermines the “all bodies work the same” assumption. All bodies do not work the same.

In fact, the limits to this assumption has driven additional medical knowledge gathering, and spawned my second favourite word in the english language: psychoneuroimmunology. It is the science of understanding the placebo. Like the DBPCT, it assumes all bodies function the same, but we need to understand more discretely the way they function, and the inputs that affect the output (health or illness). This is normal.  We usually surround a problem with a wall and try to contain it.  This is the very reason for the placebo control  And for psychoneuroimmunology. (I love to say it; hate to type it)

Assumption 2.  Sickness is standardized.  Along with all bodies function the same, there is this assumption that all bodies get sick the same way.  You can see the falseness of this assumption when you ask a group of friends what makes them feel better when they have a cold. Some feel better in warm rooms, some in open air, some in the morning, some at night.  If one illness entity, “the common cold” has so many different manifestations (and we’re talking almost all the time in almost all cases) then how can we conclude that a) all bodies are the same and b) all illness manifests itself the same way.

So medical history helps us to explore these ideas. It shows us how our assumptions are rooted in our culture, just as the explanation about blood letting or leeching or using mercury to treat syphilis was also rooted in a complex physiological understanding of the place of the body in society.  BTW, recent research has shown that mercury does have some effect on the syphilis bacillus, further suggesting that they weren’t idiots.  But also suggesting that we need recent research done properly through condoned scientific methods to convince us of this fact.

Moreover, medical history does give perspective. It permits physicians to understand their social role along with their medical role.  A number of important books underscore this, none less impressive than Susan Sontag’s Illness as Metaphor.  A critical literary scholar, Sontag was diagnosed with cancer in the early 1970s. She was surprised and offended by the way physicians and the general public layered metaphors on cancer patients, and argued that the metaphorical construction of cancer as an embarrassing illness that was probably the fault of the individual, caused way more damage and impediment to treatment than just the straight facts.  She compared the metaphors of cancer to the very different metaphors of consumption/phthysis/tuberculosis/TB of the past.  It’s a great read, and a detailed humanist view of medical history informing today. Well, informing the 1970s.  Ten years later she published AIDS and its Metaphors and explored the topic in more detail, and from a less angry perspective. It was no less influential.

I teach using such texts, and it allows health science students to understand the cultural forms we place on top of biological processes.  As an historian, it is tremendously satisfying to see lights go on when students begin to understand how our ideas are a reflection of a moment in time.

The other thing I like to note is how the stuff I study specifically can inform medical practice. Here is that argument.

People often look to health practitioners, especially physicians, as “experts in life.”  That is, we look to them for a range of answers far beyond the biological and physiological function or dysfunction of our bodies.  Health policy, public health intervention, broader issues of population health, these are the sorts of things that policy makers, media, and everyday people look to physicians (and increasingly nurses and pharmacists, but still usually physicians) to help to address.

Understanding policy, its formation, the politics and economics that underpinned the change, is important.  If we look at a current issue of allowing pharmacists and nurses and nurse practitioners to prescribe controled drugs, we can see the way the idea of drugs as bad came about, and how it was as much a political as a biomedical issue. Indeed, as I’ve argued elsewhere on this blog, it was mostly political and economic.  This understanding can help us question the assumptions behind both resistance to the change, and the advocacy for the change.

Terms like of “danger” “poison” “control” “knowledge” “experience” and “authority” abound.

So wherefore medical history?  Because it helps to excavate the foundation of our current knowledge, gives context to what health practitioners do, and can answer many questions about today that some may not even think to ask.

(c) 2014 Dan Malleck