Guest Bio:
Dr. James Le Fanu – Retired General Practitioner, author, columnist and historian of science and medicine. His books include The Rise and Fall of Modern Medicine (1999) which won the Los Angeles Times Book Prize in 2000, Why Us?: How science rediscovered the mystery of ourselves (2009) and Too Many Pills: How too much medicine is endangering our health and what we can do about it (2018).
List of question themes and full question:
- COVID & medical advancements – It’s been about 10 years plus, at least, since your revised version of rise, and fall of modern medicine. Have any of your thoughts changed about the successes and failures of medical science, or science in general, especially with the current COVID situation, mRNA stuff and so on?
- Role of capitalism – In “the rise and fall” there’s an optimistic half where you talk about the rise and there is this mention of how these immense forces, like capitalism came into play, to fund the new research into all these drugs. So in some sense, wasn’t something big, important for that that rise? But then, at the same time, you have the paradox where that same big structure has now contributed to its demise. Do you see this as a structure that we need to get rid of now that we’ve used it up to its course. In short, can we eject it and solve the stagnation issue or is the problem deeper than that?
- Expressing unorthodox ideas – We’re wanting to ask where you got the courage to express these ideas. Because I suppose your colleagues may not be too happy given no industry participants would like to admit that they’re just stewards and not the pioneers driving it forward. I know you had the advantage as an editor of a journal back in the day that allowed you to have a general idea of what’s going on in the field. But I could also think of some lines of defense, you might have encountered from others. For example, specialists might say that you’re just glossing over the details, there’s a lot more that’s going on that you’re not, appreciating. Or they might argue that we’re just around the corner of a new breakthrough. And long time cycles are natural parts of the research process. So how do you deal with all of that when you’re really early with these ideas.
- Observing past trends – Something to point out is that you looked at the past and said, “Oh, hang on, there’s a trend here.” Is that something that maybe not many people did at the time? Which is why everyone was just so focused on going forward?
- Rises & falls throughout history – I would imagine that the rise and fall is a common trope that’s occurred across history. Be it knowledge disciplines or empires one can’t help but look at these parallels. Do you think we should be looking to other examples of these and try to figure out what to do to break out of this stagnation or should we succumb to it?
- Temporary lull period in medicine – Something interesting you pointed out in your book was that prior to the Einsteinian revolution in physics Lord Kelvin said something on the lines of “the future truths of physical science are to be looked for in the sixth place of decimals”. Do you think medicine could be in a similar state?
- More theories for medicine – So earlier we were talking About Einstein, and he was famously known for his exclusive preference for the theoretical side of physics (as opposed to experimental side). I was wondering about your thoughts on having more theories proposed within medicine. Do you think that’s currently very underrated in medicine?
- Crowdsourcing for unrecognized syndromes – I came across one of your blog posts where you mentioned something interesting where in ancient Greece or something they used almost “crowdsource” advice for unrecognized syndromes. One could go out on the street and could get the public to advise you on certain groups of symptoms you’re experiencing, that the physician couldn’t really help with. Could you maybe talk about that?
- Eugenics & symptomatology – As I was reading the part of your book where you covered the dark side of genetics (i.e. eugenics “revolution”) it’s notable that medicine as a whole goes completely against the eugenic principle, because we’re essentially, promoting survival of people who may have otherwise not survived a disease. So that’s one thing. And another thought is that medicine also relies so much on this nonmaterial realm that you talk about in “why us”, because we focus a lot on symptoms. The subjective area of symptoms is not something we just brush aside to focus on the empirical (e.g. blood electrolytes and things like that). I was just wondering if you had any comments on these?
- Medicine & non-material virtues – In your neuroscience component you talk a lot about the non-material realm (that can’t be objectively measured or detected), that it’s self-evident that it probably does exist, and in a sense, medicine relies so much on that due to its reliance on symptom information. This is because we don’t measure symptoms in any way but yet we’re acknowledging that people feel certain symptoms, and we use that to inform what to do. It’s interesting that medicine as a specialty has operated on assumptions that went against materialist narratives to start with. Would you agreed with that?
- Hyper-specialization – When reading your work it seems evident that it was written by someone who has this sense of wonder about everything around him and is well-read about a broad range of topics. Nowadays it feels like (maybe as a side effect of the stagnation), the younger generation is having to do more of just what we’re specialized to do, and to look at our subject with a sort of relative dispassion. I was wondering if you had any thoughts about that?
- Writing process & helpful skills – Kind of touching on that, that cross-discipline bit, could you take us through your book-writing process, and could you also comment on the skills that have helped your writing that were gained in the medical world and outside the medical world?
- Next book – Are you able to talk about the next book or is that something kept under wraps for the moment?
Podcast Transcript
Thank you very much Dr. Le Fanu for your time today and having this chat with us. Just before we started, I thought it was interesting to make this point. Throughout your books, there’s a lot of this, theme of serendipity and fortuitous circumstances where something happens just by accident. And that was also how we came across your book. It was because of my GP supervisor, who recommended that I read “too many pills”, because he said it’ll change my view of medicine. And ever since Sushil and I read it, we went to your other works and it was so interesting how those thoughts we’ve been having privately in our conversations, we saw it all written on paper, fleshed out. And that was really what got us interested in, the things that you think about. Thank you very much for that. With that, we’ll start off with our questions:
COVID & medical advancements
Q1: It’s been about 10 years plus, at least, since your revised version of rise, and fall of modern medicine. Have any of your thoughts changed about the successes and failures of medical science, or science in general, especially with the current COVID situation, mRNA stuff and so on?
A1: I’m sorry to say no. The fundamental thesis of the rise and fall holds, and looked at from a historical point of view, there is obviously a clear contrast between this extraordinary innovative period, which lasted from the post-war years 1945, up until the mid-70s, early 80s, and then a subsequent plateauing of innovation. And, we shouldn’t be surprised by this. I mean, all scientific disciplines go through periods of growth and expansion, and subsequent quiescence. Natural history in the early 19th century; geology, physics in the early 20th century; Because the sciences, is a question of, what is the art of the soluble which Peter Medawar pointed out, and there are only at any single point, a given number of soluble questions. I’ll put it another way, once I’ve formulated the theory of the big bang and the origin of the universe, you can’t reformulate it. That is the great idea. And one can go back and fill in the details and some of the findings, inconsistencies in the theory or whatever it might be. And my feeling is that there is a strong sense of this in medicine at the moment. That it has entered a period of intellectual quiescence and stagnation. And you can see this very clearly by, looking at the quality of the medical journals. I used to read every week the lancet and the BMJ. And it would take me an hour, or whatever it might be, and along with 20 or 30 other journals to keep abreast. Now, both of these journals are really terrible. And you can read them in about two minutes.
I mean, I’m exaggerating a bit, but I mean, that the idea of there being an intellectual discourse in medicine is no longer operant. And it’s really difficult to find something really interesting and new to write about in the telegraph every week. Let’s put it in another way. I think it’s very important that we do understand this, because it gives you a sense of, what is reasonable in terms of future progress, and where the future direction might lie. I mean, the thing about medicine is that it is an overwhelmingly empirical discipline. And the great period of innovation was profoundly empirical, whether it was the discovery of all those new drugs (very often by accident or by screening 10s of 1000s of compounds for anti-cancer activity) or luck/serendipity and so on, it was profoundly empirical. And technology was profoundly empirical. open heart surgery, bypass machines, whatever it might be… Producing well worked-out solutions to well defined problems.
And what happened in the 80s is that as this rate of empirical innovation declined, so arose, the idea that we have to understand biology (medicine at its most fundamental level) and that is where the future lies. So we move, because of various technical innovations into genetics and neuroscience in particular, and this is the 20th anniversary of the sequencing of the human genome. But one could write the contribution of the Human Genome Projects to medicine, on the back of a postage stamp. I mean given the enormous amount of energy and enthusiasm, millions and millions of papers, it’s terribly difficult to discern really. I mean, obviously, there are exceptions, you had the ability to sequence the end of COVID viruses, obviously a case in point, but even then, one might say that it hasn’t really made much difference to our ability to control or manage it. On the other hand one could say that the progress in the empirical side, which is essentially to do with keyhole surgery has been spectacular. The empirical tradition is maintained in surgery. But the notion that in understanding the basic phenomenon of biology and that you can’t get any more basic than the genome has been one of the greatest disappointments to science. I think that we have to understand why that is.
And it is that the biology of disease is profoundly obscure, just as biology itself is profoundly obscure. And what the Human Genome Project and all these projects have taught us is that they’re incredibly difficult to get from the monotonous sequence of genes strung out on double helix, to the richness and diversity of the living world, Even more difficult to get from that sequence of genes to the phenomenon of disease. And which brings us to, as it were, the great unanswered questions, which remains unresolved, which is that we don’t understand the basic causes of 90% of the diseases in the medical textbook. We just don’t know what causes psoriasis, arthritis, diabetes, multiple sclerosis etc. And that’s the point that I make in the ‘Rise and fall’. And the idea that somehow or other, you’re going to find the answer from the genes seems to me to be completely absurd. And the very problem of the research enterprise at the moment and big science of genetics and neuroscience is that of course, it can produce results, e.g. papers that you can write in nature and all that sort of thing. But the practical consequences for medicine remains vestigial. Because in a sense, one is asking the wrong question.
And the thing is that because these are such vast projects, massively funded, and because of so many reputations riding on it, it’s very difficult for anybody to say, Well, hang on, what does all this add up to?
I’m not a cynic or anti-science in any way, but actually wishing there could be more. But there is this line that “under the banyan tree, nothing grows”. And under the banyan tree of big science, creative, original, counterintuitive, good old-fashioned imaginative science is absent.
Role of capitalism
Q2: In “the rise and fall” there’s an optimistic half where you talk about the rise and there is this mention of how these immense forces, like capitalism came into play, to fund the new research into all these drugs. So in some sense, wasn’t something big, important for that that rise? But then, at the same time, you have the paradox where that same big structure has now contributed to its demise. Do you see this as a structure that we need to get rid of now that we’ve used it up to its course. In short, can we eject it and solve the stagnation issue or is the problem deeper than that?
A2: It is imperative for the pharmaceutical industry to remain profitable to innovate.
And this is the point, they’re making too many pills. The problem is that
when the genuinely useful ideas dry out, then you will have to grow the market in another way. This is something which the pharmaceutical industry has done successfully in expanding the range of people it wants to sell its product. And that means to the healthy. There are more healthy people than ill people and hence, the rise of mass medicalization.
This is of course very bad for people and for medicine, generally because of iatrogenic consequences etc. The pharmaceutical industry in its early years was an incredibly optimistic, powerful drive and it could have only taken place under capitalism and it remains profitable and incredibly influential. But the adverse consequences in terms of the benefits for health of the population…. here it’s the same stagnation story in a rather different way. With the disappointments surrounding cancer chemotherapy and there’s this extraordinary situation now where billions have been spent on these anti-cancer drugs, which basically do next to nothing, increasing life expectancy by a few months or so. And that too is something which is driven by the capitalist mentality because, of course, there is a sense that people when they do get a diagnosis of metastatic cancer they’d go with anything and you can exploit that very successfully as indeed they have done. But in spending billions on cancer chemotherapy, you’re not spending billions on other things which might be far more useful.
As it were, one could say that the worm has turned and the same imperative that sustained the rise of medicine is responsible for quite a lot of it ills. It’s not necessarily something one can do anything about, but people should be aware of it.
Expressing unorthodox ideas
Q3: We’re wanting to ask where you got the courage to express these ideas. Because I suppose your colleagues may not be too happy given no industry participants would like to admit that they’re just stewards and not the pioneers driving it forward. I know you had the advantage as an editor of a journal back in the day that allowed you to have a general idea of what’s going on in the field. But I could also think of some lines of defense, you might have encountered from others. For example, specialists might say that you’re just glossing over the details, there’s a lot more that’s going on that you’re not, appreciating. Or they might argue that we’re just around the corner of a new breakthrough. And long time cycles are natural parts of the research process. So how do you deal with all of that when you’re really early with these ideas.
A3: Yeah, well it sort of happened by accident, in a way. I had been attending some seminars on 20th century medicine, which were organized by the Wellcome institute in the early 90s. And a lot of the people who had been involved in the rise of medicine, they’re coming up for retirement or have retired and had time to come and talk about what they’d done. And it occurred to me, “Well, this is an extraordinary story, which hasn’t been written.” And so I contacted 20 or 30 people of that generation. I did a grand tour of Britain and visited them all, and then I corresponded with others in France, America and so on. And in a sense, that part of the story told itself.
As soon as you started charting the way in which medicine had risen during that period, of course almost immediately the question that began to arise is, here we are (I was writing this in the nineties), and it was very striking how, the rate of innovation has declined, and no one seeks explanations for that.
But I was also driven by my skepticism about genetic determinism, and the rise of the new genetic ability to explain disease and things because I’m an anti-reductionist. And I don’t believe in this idea of understanding things, at a more and more profound level. I mean, we do understand things on a more profound level, compared to say, back in the 16th century. But at each level of understanding, a whole series of other questions remain unanswered. So whatever the genes will tell you, it won’t tell you anything about how the cell works, really. And how the tissues work and so on. So there’s, all that explanatory gap. As medicine threw all its eggs into the single basket of genetics, I didn’t think that was going to go anywhere. And I was also quite intimately aware of how misleading so much epidemiology was and what passes for epidemiology, especially the epidemiology of common diseases, and so called diet-disease hypothesis and so forth. And so in writing it, I was conscious that there were these substantial intellectual problems in what were increasingly dominant forms of medical inquiry and research. So in that sense the story told itself and the historical perspective teaches you a lot. In a way it seems prescient. Perhaps at the time when I first published the ‘Rise and Fall’ in 1999, I would have thought that my original verdict has been pretty much vindicated. And, in fact, what I failed to appreciate was just how bad things could become. I didn’t anticipate the way in which the pharmaceutical industry would solve this problem of lack of genuine innovation by seeking to grow the market by mass medicalisation. The thing is that I was able to write about these because I was outside the academic structure. I didn’t have an academic post and things didn’t depend upon it. And so one could be the Cassandra of this discipline. If my research funding depended on talking up the latest idea, then obviously I wouldn’t have been able to write it.
Observing past trends
Q4: Something to point out is that you looked at the past and said, “Oh, hang on, there’s a trend here.” Is that something that maybe not many people did at the time? Which is why everyone was just so focused on going forward?
A4: Yeah. Well, I mean, big science and capitalism are driven by the idea of progress. And capitalism has to grow. It’s “grow the markets” “grow the profits” “expand” that it’s all predicated on. That’s the way in which one generates wealth. And science. it’s not a philosophical enterprise. The whole phenomenon of scientific publishing is predicated (or everybody’s careers is predicated) on writing papers. We have to say something new that hasn’t been said before. Progress is sort of built into it and of course that’s a dynamic thing, which gives it its motif. But it doesn’t necessarily mean that one has to be persuaded by the direction it’s taking. There’s an interesting, analogy here with a much bigger picture, which is sort of what I talk about, in “why us”, that in my lifetime, we have understood the history of the universe from the moment it started till yesterday. It has happened in the last 50-60 years. It’s an extraordinary thing. How chemicals were formed in the stars and how the atmosphere was formed etc. And we didn’t know that 50 years earlier. And the problem then is, once you’ve done that, it’s very difficult to know where to go, which leaves science in a quandary. And that applies obviously, to genetics. We have these vast departments of neuroscience but the thing neuroscience has taught us in the last 15 or 20 years is that you can’t get from the electrochemistry of the brain to the wishes of the human mind. I mean, we can understand the brain down to the last atom. Yet, it will not begin to account for how we can have this conversation at the moment. There is more than we can know and these are profound scientific problems for which there may not be scientific answers.
Rises & falls throughout history
Q5: I would imagine that the rise and fall is a common trope that’s occurred across history. Be it knowledge disciplines or empires one can’t help but look at these parallels. Do you think we should be looking to other examples of these and try to figure out what to do to break out of this stagnation or should we succumb to it?
A5: It depends on what extent one thinks that the current intellectual gridlock in science and medicine is a consequence of the way in which science is organized. If it is a consequence of the demands of big science, where unless you have some research project which amounts to several million pounds, just forget about it, because you’re never going to get it. And if that is having a sort of deleterious stifling effect on genuine originality of thought then that is theoretically remediable. Because you just recognize that fact and you say big science have failed to live up to their expectations, we will now shift direction and start funding people who’ve got good original ideas. And one could see that as a way that another rise might happen. But I think by the time most people live out their natural lifespan they die from diseases strongly determined by aging. The prospect of continual advance is limited outside (as I said) the great unsolved question in medicine, which is, “what is the cause of common illnesses?” And that requires an intellectual revolution on the scale of the discovery of germ theory of disease or something of that sort. A monumental paradigm shift. That is the example I cite in the “rise and fall of medicine”, which is, there has to be a cause for the diseases just as H. Pylori was identified as the cause of peptic ulcer disease and thus became treatable. Who’s going to do that? I don’t know. I must say the cause of disease remains very, very obscure. It might need Einsteinian level of imagination for an explanation. Because obviously, science is missing something but we don’t know what it is.
Temporary lull period in medicine
Q6: Something interesting you pointed out in your book was that prior to the Einsteinian revolution in physics Lord Kelvin said something on the lines of “the future truths of physical science are to be looked for in the sixth place of decimals”. Do you think medicine could be in a similar state?
A6: Yes it could be. My interest in the last few years has really shifted away from thinking, where does the future of science lie to the much more practical question of how can we minimize the harms that is currently in effect, because that does seem to me something which is readily remediable, which is the arguments in “too many pills”. But even that is pretty difficult because of course, the pattern of mass medicalisation is now so deeply entrenched in routine medical practice. It’s very difficult to eradicate. And the curious thing is it’s one of those things that everybody should know but don’t seem to know; And that is physiological variables rise with age. Blood pressure of an 80-year-old is different from that of a 25-year-old. And we fail to take that into account. That is an absolutely fundamental biological fact. And so much of the iatrogenic illnesses that one finds in the older age group is, is predicated on a biological falsity; the suggestion that you should normalise blood pressure or whatever physiological variable down to levels that’s seen in the younger age group. And I would like to think that there’s a wider acceptance of that. The analogy I use in “too many pills” is an extraordinary story about how back in the 50s and 60s, if you had a coronary you’re put in bed for 3 months (on the basis that the heart had to heal). But mortality rate was 30 to 40 % (e.g. from an emboli). That idea was overthrown. And I think the same could apply to mass medicalization in the elderly. Unfortunately one of the effects of the covid pandemic is that everybody becomes obsessed with covid and any other interests in wider medical questions get pushed aside.
In fact, we were making some advances in tackling overtreatment, overdiagnosis and so on. But it is all in the background now.
More theories for medicine
Q7: So earlier we were talking About Einstein, and he was famously known for his exclusive preference for the theoretical side of physics (as opposed to experimental side). I was wondering about your thoughts on having more theories proposed within medicine. Do you think that’s currently very underrated in medicine?
A7: There is this thing called the meso level, which is somewhere between the macro and the micro level. And the idea that one looks at the phenomena of disease not at the level of genetics (or that sort of thing) but at the level of tissues or organs. That’s one interesting way of looking at things.
I think the idea of the microbiome, is a very interesting example of how lateral thinking can be intellectually productive. I mean that is essentially a completely novel idea. And potentially very productive. I can’t say I’m quite sure how it came about. But I mean, I think irritable bowel syndrome is an interesting case in point here, because it is common, there’s no obvious physical cause for it, and so it’s easy enough to say it’s a somatization disorder or essentially psychological when clearly it’s not.
But there was no way into understanding it intellectually until somebody came up with a novel idea (i.e. microbiome) which is a possibility to be explored further. But I think it’s a very interesting one, because it’s this whole thing about symbiotic relationships, which is endemic in nature. And the idea that our symbiotic relationship with microbes in our gut might be a cause of disease, illness or symptoms… That’s a really interesting and original idea and you’d wonder whether or not there are other ways in which it might be extrapolated. So, yeah, all praise to the microbiome, because it does in a way, point to a few future directions and it shows that seemingly intractable issues might be open to interpretation. I think that this in a way applies to IBS and a lot of these other so called somatization disorders (e.g. chronic fatigue syndrome). I would like to think that that provides a clue to future progress. It would require that one accepts the limitations of the notion of somatization as an all-encompassing explanation for symptoms of unknown cause.
Crowdsourcing for unrecognized syndromes
Q8: Speaking of syndromes I came across one of your blog posts where you mentioned something interesting where in ancient Greece or something they used almost “crowdsource” advice for unrecognized syndromes. One could go out on the street and could get the public to advise you on certain groups of symptoms you’re experiencing, that the physician couldn’t really help with. Could you maybe talk about that?
A8: Yeah I will. I think that I do have a big interest in, not obscure syndromes, but things which can be difficult to diagnose, and which might be individually rare, but collectively quite substantial. One of the great thing about writing is that you have 500,000 readers approximately, or used to. That is vastly more on an order of magnitude than the number of patients you’re likely to have on your books as a general practitioner. And so their collective experience of 500,000 people is much greater, and so even things which might seem to the GP “I’ve personally never come across this. This doesn’t seem to fit any well-known syndrome. You must be having a somatization disorder, you have medically unexplained symptoms.” But you mention it in the telegraph and there will always be two or three, 5, 10 people who say “that’s interesting I have a very similar set of symptoms”. So, yeah I wrote this up for the journal of the royal society of medicine and suggested that we had between us identified 40 never previously acknowledged or diagnosed syndromes and some of them weren’t completely obscure, I mean very often one could find a cause for them, and which were overlooked by doctors. The periodic symptoms particularly and which are as they were variations on migraine type syndromes and the dysautonomias which produced a series of unpleasant symptoms which aren’t necessarily in the medical textbook. The thing is, even though one doesn’t necessarily have a cure or remedy, there is a consolation of sorts for knowing that you are not just imagining it. And this particularly applies, I think, to which I found more recently to this phenomenon of, unexplained symptoms, which turn out to be obscure side effects of one or many pills that people are taking nowadays. And so, this week for example, somebody writes in and says, “I’ve been suffering from burning mouth syndrome, otherwise known as scalded tongue syndrome. None of the treatments seem to work, it’s an illness of unknown causation, and can be very problematic, and so on. And I’m taking a variety of pills…”, and included amongst them was an ACE inhibitor, lisinopril, and it takes you all of five seconds to google ACE inhibitors burning mouth syndrome, and discover that indeed there are 15 reported cases. And that if you stop taking it, it gets better. I think there are cases that can be enormously helped by google, which allows you to make the sort of connections which you wouldn’t be able to make otherwise. That’s an area of growth that can be expanded on, and certainly, I think is something that GPs should be more aware of. That just because something doesn’t fit into something you know about, doesn’t mean that there might not be an explanation for it, or that it might not be a recognized collection of symptoms. That together with writing on hazards of mass medicalisation has been major contributions to medical practice. And, in fact, I’m sure I’ve done vastly more good in my career as a doctor telling people to stop taking pills than putting them on them.
Eugenics & symptomatology
Q9: As I was reading the part of your book where you covered the dark side of genetics (i.e. eugenics “revolution”) it’s notable that medicine as a whole goes completely against the eugenic principle, because we’re essentially, promoting survival of people who may have otherwise not survived a disease. So that’s one thing. And another thought is that medicine also relies so much on this nonmaterial realm that you talk about in “why us”, because we focus a lot on symptoms. The subjective area of symptoms is not something we just brush aside to focus on the empirical (e.g. blood electrolytes and things like that). I was just wondering if you had any comments on these?
A9: Yes, I think the whole eugenesis story is absolutely fascinating. If looked at now, with the rise of wokism, all these great champions of scientific materialism in the late 19th century and early 20th century, a lot of them seemed to have these very reprehensible theories or conceptions of human life. And much as people might try to excuse Darwin, they are an inevitable consequence of his theory of natural selection. Not to say that evolution doesn’t happen, I’m sure it does. But what we don’t know, is, what is the mechanism? How did it come about? One of the most interesting aspects of the last ten years is here you have this vast all-explanatory theory in science, where everything is as it is because it has evolved to be that way over millions of years. There is nothing to which science doesn’t have the answer. And anybody who says that science doesn’t have an answer is called a creationist. The question is where are those random mutations that are meant to have driven the evolutionary process? And they are nowhere to be found. You can ransack as many genomes as you want and nothing would tell you what it is that distinguishes us from a fly.
So, that’s a really interesting one. But, science has become so wedded to the fact that Darwin explained all these things that it’s very difficult to see how it can be dislodged and anybody who raises doubts about it is of course immediately condemned as being anti-science. And there’s nothing like that for destroying originality of thought. It’s an intellectual straightjacket. Extrapolation of ideas of some of those people who’ve been hailed as the heroes or founders of scientific materialism, have had undesirable and devastating consequences. The problem is the problem of any all-explanatory theories. Things that explain everything in general end up not explaining very much in particular, and that is certainly the case with Darwinian evolution. This is not to deny that evolution didn’t happen. The history of the universe is an evolutionary history; things going from simple forms of matter to more complex ones. Whether we understand that process is another issue.
Medicine & non-material virtues
Q10: In your neuroscience component you talk a lot about the non-material realm (that can’t be objectively measured or detected), that it’s self-evident that it probably does exist, and in a sense, medicine relies so much on that due to its reliance on symptom information. This is because we don’t measure symptoms in any way but yet we’re acknowledging that people feel certain symptoms, and we use that to inform what to do. It’s interesting that medicine as a specialty has operated on assumptions that went against materialist narratives to start with. Would you agreed with that?
A10: I think that, medicine is predicated on non-material virtue of sympathy, empathy, compassion, intellectual inquiry and seeking of truth, all of which don’t have any material basis. And the practice of medicine is a humanistic discipline. You understand what is going on not by being terribly scientific but by listening carefully to what the patient has to tell you and inferring what the likely explanation might be, which in a way defies any sort of mathematical algorithm. A combination of experience and insight leads you to the correct diagnosis and that is a non-material sort of phenomenon. I think one could say that (if I wanted to be overly pessimistic) one of the unfortunate consequences of the rise of diagnostic technology is that, that happens less, or less than it used to. And so the answer to any particular problem is to have an MRI scan without even engaging the patient in the conversation of what the symptoms might be.
As the quote says “People get the art and science of medicine the wrong way around.” The art is the “being nice to patient” part and the science is the hard bit, where it’s actually the other way round. The art of listening is where you find out what’s really amiss. And the science can often be misleading. It’s an interesting counterintuitive way of looking at it.
Hyper-specialization
Q11: When reading your work it seems evident that it was written by someone who has this sense of wonder about everything around him and is well-read about a broad range of topics. Nowadays it feels like (maybe as a side effect of the stagnation), the younger generation is having to do more of just what we’re specialized to do, and to look at our subject with a sort of relative dis-passion. I was wondering if you had any thoughts about that?
A11: I mean, of course, the future does lie is specialization, doesn’t it? In the sense that, that is the way it’s going. And specialists do get better results. A way in which one can look at a career in medicine now, is to see it as being a technical function. You’d get the permission to do something, and then you can, as it were, chart your career on that base. The limitations of a specialization is that it gives you tunnel vision.
The career progress in medicine is very much, if you want to have an “easy life”, is to find the one thing that you’re good at and do it. And that is the sort of way it turned out. One could say, well, you can do that, but you should also maintain an interest in the broader intellectual and philosophical ideas in medicine. Everybody should do that. But that becomes more difficult with the decline in quality of the medical journals. And it becomes even more difficult with everything going online. I used to go to the Royal society of medicine library once a week, and I could scan about a 100 journals. You just had to look at the contents, see if there was anything that struck you, interesting or original, and so on. And you can’t do that any longer. What I mean is that, that sort of general intellectual discourse is more difficult to achieve than it was in the past.
I do urge people that they should nonetheless, make the effort and one way to do that is to join the Royal Society of Medicine and go onto their website, and then they have access to 2000-3000 journals and you just select two or three of the more general ones and you should scrutinize their contents page once a month, just to see what’s going on. And I’m not unsure that many people already do that. But, it’s what I do, and it’s how I maintain what everybody should have, which is not necessarily a specialist knowledge, but an overarching Olympian view of what is going on generally. And to be able to make connections across disciplines and see that something which is happening in one is happening in another and so on. Everyone should cultivate their imaginations. An interesting thing about medicine is that it recruits at a very high level now. Much higher than it used to be.
It used to be such that you didn’t have to be, an intellectual superstar. And that, in many ways, is actually a rather good thing. Because you can be too clever to do medicine. And one of the problems is that, if you have a lot of clever people going into medicine, they get bored, and that’s not a good thing. Whereas what you want to have is people who are scientifically literate and are quite happy to go and bat away in general practice for 40 years, get to know their patients and do that sort of thing. And you don’t need to have a lot of molecular biology for that. My point is that medicine does recruit at a high level now and they need to get into the humanities and expand beyond specialized science. A little bit of literature, philosophy and that sort of thing. These things aren’t difficult.
Writing process & helpful skills
Q12: Kind of touching on that, that cross-discipline bit, could you take us through your book-writing process, and could you also comment on the skills that have helped your writing that were gained in the medical world and outside the medical world?
A12: I think the thing about medicine is that you have to get to the truth. You have to get the correct diagnosis and there’s no point in being half-right. There is a great incentive to that “what is really going on here?” question. It’s a great intellectual stimulus. And that applies in the clinic, but also applies intellectually. And so, my interest has been, “what is really going on here?” And for that, you have to read extensively (which I enjoy enormously and is the most pleasurable aspect of it). You read an article and you check the references to the article and you pursue the references. “Where did the reference come from?” “Where did this idea come from?” So there’s that. And I like originality of thought. I like people who think differently from everybody else. I mean one might say everybody likes that. It has a special appeal. So I read a lot, I like being in the library and I like digging out obscure references and seeing how everything fits together as it usually does. In terms of writing about it, I mean there’s no doubt that writing a medical column on the telegraph for many years is a very useful discipline because it means you have to think about how to express this in ways that other people would understand and that requires the ability to explain complex things in simple ways (but not overly simple) and in a way that grabs the attention of the reader and it is a certain sort of discipline. I mean, there are people who are much better at it than I am, but that helped. As for the other question, there is a bigger philosophical story. Which is “How much do we know? how much can we know?” I am very much persuaded that there is more than we can know and that is a metaphysical way of viewing things. I’m not persuaded by literalistic explanations. And I’ve got one more book to write and then that’s it.
Next book
Q13: Are you able to talk about the next book or is that something kept under wraps for the moment?
A13: Yes, well, sort of. I’m very interested in natural history and the world out there. And there isn’t (interestingly) a history of scientific natural history. I mean, there isn’t a history of what we’ve learned in the last 100 years since the 1920s. Of course everybody knows of the rise of natural history in the 19th century (Darwin and that sort of thing), but what is it that we’ve actually learned since then? And how extraordinary it is! It’s the extraordinariness of the ordinary. Wondering why it is that there are so many different shapes of leaves, which sounds like a really simple question doesn’t it? How the sap rises? That’s great stuff. I can see myself being amused for another few years writing that.