Georg Ivanovas From Autism to Humanism - systems theory in medicine
2.1 The medical paradigm
There is an underlying conflict in all diagnostical and therapeutical process which has been called the opposite between generalisation and individualisation. The last 150 years there has been a tendency towards generalisation. Diseases are defined by general characteristics. Individual aspects are mainly neglected. The concept of therapy follows a regimen that has proved to be beneficial for populations. The individual case is not sufficiently taken into account. The NNT, the ‘number needed to treat’, describes how many patients have to be treated in order that one patent benefits of the treatment. “NNTs under 5 are unusual, whereas NNTs over 20 are common” (Smith 2003e). Therefore, it become more and more necessary to understand, what really helps the individual and not a population.
Today’s individualisation is called tailored therapy. Tailored in this sense means that a therapy should be based on the patients responsiveness. That is, the individual reaction of the patient as a whole has to be considered. There had been a certain hope that genetical testing will enable to sort out susceptible patients. But this hope quickly dwindled away (Judson 2008).
Methods which tried to influence inner regulation (chap. 6.3), like psychotherapy or balneology always individualised and tailored their therapies. Their observations suggest that a broader view of the individual and his abilities is necessary. In order to attain a certain goal, equifinal processes (chap. 4.7) can and have to be activated. The unique situation of a patient has to be understood. Pierre Schmidt, a famous homeopath, has been asked by a patient, whether he had seen already a similar case as hers. He answered: “I hope not”. This is in a nutshell the basis of individualisation. For individualising methods the diagnosis is less important. Some methods even do not have a diagnosis, respectively, as in homeopathy, the diagnosis is synonymous with the therapeutical strategy (translated into orthodox medicine: a methotrexate-case).
This opposite of generalisation and individualisation has been formulated and discussed in many different ways, stressing always a different aspect:
or for psychotherapy (Fiedler 2001)
The underlying problem shall be demonstrated with a study which investigated the effects of the firmness of a mattress on the clinical course of low back pain. The problem might sound to be of secondary importance, at first. But whoever listened to patients with chronic low back pain knows that it often is an issue that decides on the well-being of the patient, his fitness for work, the family climate and the happiness of everybody. Kovacs et al. performed a randomised, double-blind, controlled, multicentre trial. The study was carried out for 90 days. It found that patients “with medium-firm mattresses had better outcomes for pain in bed (odds ratio 2·36 [95% CI 1·13-4·93]), pain on rising (1·93 [0·97-3·86]), and disability (2·10 [1·24-3·56]) than did patients with firm mattresses. Throughout the study period, patients with medium-firm mattresses also had less daytime low-back pain (p=0·059), pain while lying in bed (p=0·064), and pain on rising (p=0·008) than did patients with firm mattresses” (Kovacs et al 2003). But up to 10 % in the group with a medium-firm mattress had more pain.
This result produces a methodological problem. If everybody is advised to sleep on a medium-firm mattress, 10 % might have more pain. Such a schematic procedure would be no good medicine. Therefore the physician will have to ask the patient about his experience and change the therapeutic means according to the actual observations. But then all kind of other issues (the theory of the physician and the patient, the climate of the communication and many other aspects) will play a role. This creates a fundamentally different situation than that of a blinded trial. Thus medical practice becomes always individual.
Even surgeons who want to see patients only in narcosis individualize with every movement. Or in emergency medicine where patients are seen in coma or under circumstance where they cannot communicate, individualisation is absolutely necessary. Did the patient take drugs or medicine? Does he suffer from a chronic illness? That is, also therapy in emergency is individual. One of the first principles I learned in the education in rescue medicine was: ‘Forget the equation 1 patient = 1 ampoule. Give a dose you think is necessary for this special patient (age, weight, seriousness, hypothesis of the problem). Then look at the reaction. Repeat or change the treatment according to the observation. Being too courageous harms. Being too reserved harms.’ Everybody who worked in rescue medicine knows the highly beneficial effects of a correct, individual action and the disastrous effects of schematic, non individualizing approach. Knowledge is important. But it is only a guide line. Rescue medicine is based on the individual decision of an individual doctor seeing an individual patient in an unique situation.
Rescue medicine is but a burning glass of all medical action. Every therapy has to be conducted in taking the patient’s resources and reactions into account. A schematic procedure is mostly harmful, at least for a certain part of the patients. Therefore the claim of an acupuncturist, never to treat two people the same way (Worsley 1982: 23) is equally true for general medicine. However, in chronic diseases the processes are slower and the patient has more reserves to resist certain faults of a schematic therapy.
In acute cases the physician understands quickly whether his treatment is beneficial or not. In chronic diseases this is much more difficult. A tool which might be helpful to understand how a therapy develops might be found in the concept of biological hierarchies (chap. 6.12, appendix VI).