Science, Clinical Practice, and a Synthesis of Both

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When I first practiced medicine, many treatments I prescribed were not backed up by solid evidence. Some have been abandoned as ineffective, harmful, or both. Today, clinicians stand on somewhat more solid ground, but it would be naive to believe that all treatments are truly effective. Yet clinicians use them, and patients generally get better after receiving them. Throughout the ages, physicians have interpreted clinical improvement as the direct result of their interventions. These observations are added to an ever-growing body of medical anecdotes; many are incorporated into clinical practice.

Scientists, often far less impressed by clinical experience, feel compelled to point out that observations have to be interpreted with caution. They insist that causal inferences between an intervention administered in routine care and the reported clinical outcome are normally not possible because too many factors are at play.

One powerful element likely to alter the strength of clinicians’ experience is selection bias. Imagine that a physician treats 100 patients for a particular ailment. Those who improve will tend to say so; those who don’t will tend not to come back. Over the years, this continuous process of selection would produce a falsely positive impression about the treatment.

A second phenomenon that weakens the reliability of clinical observations is the complexity of the therapeutic response itself. Physicians are inclined to assume that improvement results from the specific effects of their treatment. Scientists know this assumption is wrong. It neglects a host of nonspecific influences and artefacts likely to inflate the therapeutic response. Natural history of the disease and the placebo effect are 2 potential confounders that are obvious to most clinicians. Other factors are rarely considered.

For example, patients often consult their doctor exactly when symptoms are at a peak; regression towards the mean describes the fact that extreme values return to the mean no matter what they are or what we do. The clinician-patient interaction relates to empathy, warmth, and understanding, which skilled doctors, during the course of several consultations, manage to establish. It can reassure the patient and help generate a sense of improvement regardless of the efficacy of the actual therapeutic plan. Concomitant treatments are used by many patients—often without the clinician’s knowledge. Obviously, additional therapies can enhance recovery, and positive changes might easily be misinterpreted as an explicit result of the physician’s original regimen.

Social desirability describes patients’ inclination to be kind to the doctor, a proclivity that is especially pronounced when patients feel they were treated with compassion. In this scenario, patients might say they are much improved when in fact, they are not. All together, these phenomena increase the perceived therapeutic response. For clinicians, this is a bonus; for scientists, it constitutes a complexity that requires disentangling. They feel obligated to gauge the relative size of each effect so that therapeutic strategies can be refined.

Can the tension between scientific investigators and medical practitioners be lessened? Perhaps both camps should stop squabbling over the moral high ground. Scientists have to realize that patients’ views are pivotal. If a treatment route alleviates symptoms, patients are convinced of its effectiveness. When accounts of their improvement are then questioned simply because the information does not yet tally with scientific proof, they become justifiably irritated. Perhaps scientists should regard this discrepancy as a starting point for researching the more intangible elements that contribute to an apparent medical benefit. A deeper understanding of the complexity of the therapeutic response would undoubtedly be a significant advance.

Clinicians, on the other hand, should consider that medicine involves more than helping the patients they are attending to today. We all have a responsibility for improving tomorrow’s healthcare. That accountability is best served by a self-critical attitude. If medical progress is to be made, physicians have to look beyond the immediate desire for a patient’s improvement to the myriad data points that warrant collection and a thorough investigation. Good medicine recognizes the necessity of research and applies its best findings, along with the still untested practices that seem to make patients feel better. In other words, practitioners should continue to embrace not just the science of medicine, but the art.