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As generations of medical students have testified, foremost among them is learning to recognise the abiding presence of uncertainty in medicine and to deal with its daunting implications, reasons Prof. Ashoka, in the sixth part of his research paper. A Different Truths exclusive.
More is called for than earnestness about emphasising these components of educating physicians-to-be, or astuteness about how to blend them into the medical school curriculum and teach them with intellectual clear-sightedness, clinical relevance, and socio-psychological timeliness. It is also essential that this be done with attunement and responsiveness to the issues medical students are facing that emanate from the scientific and clinical state of the field they are being prepared to enter. These issues are attitudinal and philosophical, as well as cognitive and practical in nature.
As generations of medical students have testified, foremost among them is learning to recognise the abiding presence of uncertainty in medicine – uncertainty that exists both inspite of and because of the vast knowledge and powerful skills that medicine commands – and to deal with its daunting implications. In the view of physician and historian Kenneth Ludmerer, training physicians to handle uncertainty as they carry out their preventive, diagnostic, therapeutic, and prognostic work in medical practice is, and should be, a primary goal of medical education. It is a goal that he also characterizes as exceedingly difficult to achieve – one that he calls medical education’s “most elusive ideal.”
…what I have termed the process of “training for uncertainty” has seemed to me to be as basic and demanding as Ludmerer states – a challenging quintessence of becoming a physician and of practicing medicine.
From the outset of my involvement in first-hand research on the education and socialisation of medical students during the 1980s what I have termed the process of “training for uncertainty” has seemed to me to be as basic and demanding as Ludmerer states – a challenging quintessence of becoming a physician and of practicing medicine. If anything, it has become even more important during the past few decades, as changes in medical science, technology, and practice, and the social and cultural conditions surrounding them, have contributed to the appearance of new manifestations of medical uncertainty – and, in some respects, have enhanced or complicated long standing, older patterns of uncertainty.
A momentous source of current medical uncertainty is the biological revolution that has resulted from the identification of the self-complementary double-helix structure of DNA, the ascendancy of the new molecular and cell biology with its genetic focus that this has brought in its wake, and the explosion of information and knowledge that has ensued. Despite the promise of these spectacular scientific developments for transforming the practice of medicine, and the high expectations that they have engendered in this regard, it is unclear when, how, to what extent, or even whether such progress will actually come to pass.
Molecular genetic testing is in its infancy; none of the gene therapy undertaken has as yet succeeded; and a wide conceptual gap, still unbridged, exists between the molecular and genetic knowledge that has been produced and the organismic, pathophysiological level on which clinical medicine is practiced. The so-called emergence and re-emergence of infectious disease· that has become noteworthy since the appearance and pandemic spread of HIV/AIDS is another major source of both new and old medical uncertainty.
Iatrogenic uncertainty has also increased in concatenation with contemporaneous medical advances.
The enhanced importance of prognosis in medical practice – to which the increased prevalence of chronic disease and its care, the development of medical technology to ascertain the in utero condition of the foetus or detect the possible occurrence of a genetics-borne disorder, bioethical emphasis on informed consent before treatment or experimentation, the development of hospice, and the growth of managed care have all contributed-confronts physicians with a plethora of uncertainties. These are engendered by the growing extent to which physicians are expected to make overt predictions about the course and outcome of patients’ illnesses and the treatments they undergo, and about their ultimate survival or expected time of death. Iatrogenic uncertainty has also increased in concatenation with contemporaneous medical advances. As the means of diagnosing and treating disease and illness have become more powerful and efficacious, they have grown more dangerous as well-confronting physicians and their patients with an expanding array of serious, unanticipated side effects that are neither easy to prevent nor easy to dispel.
The long-standing intellectual and moral tension between attending to the needs and well-being of individual patients and to those of larger collectivities of persons, and the uncertainties that physicians experience about how to reconcile these dual role obligations, have been exacerbated by the resurgence of infectious diseases and the public-health considerations that they entail; by the expansion of managed-care organisations with their aggregate orientation and distributive outlook on the efficient, cost-containing utilisation of resources; and by the ascent of what is known as “evidence-based medicine” that, by defining the most reliable and valid empirical data as those derived from large, randomised, controlled clinical trials or from meta-analyses of published studies, tends to shift the focus of clinical practice away from the care of individuals toward the care of populations.
In turn, evidence-based medicine and the debate that currently swirls around its value and its limits are indicative of the epistemological uncertainty that seems to pervade contemporary medicine. Quite paradoxically, the same current medical journals that publish an unending stream of reports on the impressive scientific, technological, and clinical advances and achievements of what historian Roy Porter characterises as modern “medicine’s finest hour” are also replete with articles that raise searching questions about how much of what medical scientists and physicians think they know is real knowledge, who can say when evidence is “good enough” and most likely to be “close to the truth,” and about how best to understand and give an adequate account of astute clinical judgment, sound clinical decision making, and the constituent elements of optimal medical care.
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