Georg Ivanovas From Autism to Humanism - systems theory in medicine

2.1 The medical paradigm

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g) the practitioner’s paradox

The practitioner has to individualize in his daily practice. However, he has never been educated to do this. He has anatomical, physiological and biochemical knowledge, knows some typical states of disease, knows about probabilities and is confronted with a single human being onto which he has to apply this knowledge.

Evidence-based medicine relies… on randomised clinical trials that emphasise efficacy: how an intervention works in a well-defined setting for a specific group of patients with a distinct disease. This information is insufficient to assist most doctors, because they have to treat less clearcut illness in indistinct patients' groups” (Maesemeer et al, 2003). But also in clear-cut diseases decisions are often made in an area of uncertainty (Chalmers 2004; Kirk et al 2004).

Guidelines cannot be based on data alone; judgment is unavoidable (Raine et al 2004), provisional hypothesis are tested (Griffiths et al 2005) and evidence plays only a partly role (Burgers/van Everdingen 2004). Actually, there is no individual evidence and the question “But does it work doctor?” (Protheroe 2003) cannot be answered sincerely.

Due to the lack of security, there is a tendency to involve patients into the process of deciding. He should be better informed, prescriptions should be made in partnership (Heath 2003; Evans et al. 2006), the probabilities and risks should be explained to him (cf. main topic of British Medical Journal 2003c), giving him a discrete choice (Ryan 2004), where the probabilities of different approaches (e.g., medical - versus invasive) are discussed according to the values of the patient (Montori et al 2005). Even “expressing uncertainty” should be a task of the doctor (Say/Thomson, 2003; Maesemeer et al, 2003).

But this is a risky path. Often the physician has not developed suitable strategies to communicate risks (Alaszewski 2005) and nothing can be said on the prospects of the single patient, especially in multi-disease or with different risk factors (Kamps 2003).

However, patients have normally a quite good ability to assess risks and come to conclusions that are in line with their personal situation (Illife/Manthrope 2003). They are not educated in reductionist thinking and might have a better ability to feel and estimate complexity, something especially true for important decisions with long term consequences.

But also the physician, notably the practitioner has developed a method of observation and understanding which I would like to call medical knowledge, in contrast to the scientific-analytical knowledge. Already Bernard stated: “We should first of all state the medical problem as given by observation of the disease, then try to find the physiological explanation, by experimentally analyzing the pathological phenomena. But in this analysis, medical observation must never disappear or be lost sight of; it must remain as constant basis or common ground of all our studies and explanations” (Bernard: 199). Medical knowledge in this sense is not scientifically organized, but essentially based on experience and intuition (chap. 4.9).

This discrepancy between the scientific and the empirical approach is not a characteristic of current medicine. Already about 2000 years ago Celsus (about 25 BC – 50) formulated the difference between a theoretical and an empirical medicine (appendix II). It is striking that the logic of the arguments has not changed since. Although the subject of research in theoretical medicine has moved from basic anatomical and physiological issues to subtle forms of physiological control there is no structural change in the arguments. On the side of the empirical medicine, the arguments have changed even less.

It seems that there is no possibility to avoid this gap of uncertainty between theory and practice. Medicine is the practitioner’s paradox. A systemic approach might be able to moderate this discrepancy by providing appropriate scientific tools. But this will not end the uncertainty due to the non-trivial status of human conditions.


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