Articles

Cargo Cult Science, Medicine, and Science Fatigue

In Medical Musings on March 7, 2011 by David Tagged: , ,

Part One: Cargo Cult Science

During the Second World War, American and Japanese forces fought over a large swath of territory across the Pacific Ocean. This area including many previously unexplored islands and archipelagoes and many indigenous cultures inhabited these distant lands. Isolated by large jumps of distance and previously unknown, these indigenous cultures were exposed to modern technology for the first time during the war. Imagine their amazement as, for the first time, they saw the metallic glare of fighter jets and battleships and heard the deafening roar of jet engines.

Food rained from the skies and the new arrivals literally changed the landscape, as both American and Japanese soldiers used airdrops and created landing strips and airports. To these indigenous cultures, the new arrivals must have seemed to be Gods or, at the very least, demons. Introducing the indigenous cultures to canned foods, medicine, clothing, and other manufactured goods, this outside intervention must have seemed incomprehensive –completely changing their world view and turning their lives upside down as they stood in the middle of a battle between two technological powers.

But then, after the conclusion of the Second World War, the soldiers left as quickly as they had come. Without a war to fight, there was no longer the same incentive to stay at these remote islands. For the indigenous cultures, it must have been quite confusing. Where did all the nice clothing, tools, and medicine go? How come food no longer dropped from the skies? Not fully understanding the reason why the soldiers came to their land or the mechanism behind the new supply of food and supplies, some indigenous cultures became cargo cults. They wanted access to the benefits and tangibles of technology without truly understanding how it worked. Mimicking the soldier’s actions and creating the outward signs of complexity, cargo cults sought to recreate the conditions required for attracting the cargo. Creating life-size replicas of airplanes, building control towers made of wood and thatch, and even clearing land to recreate runways, cargo cults mirrored the conditions of a technological society without fully understanding the reasoning and mechanism of their actions.

Richard Feynman famously used the term cargo cult science to describe research that is done without a full understanding of the underlying mechanism and using “reason” to justify the results post-mortem. Although these imitations can be quite accurate – Feynman mentions that the straw antennas of these make-shift airplanes were strikingly close to the length of actual antennas – without having any kind of result. Although mimicking the routine of developing hypotheses, using controls, and performing experiments, cargo cult science describes work that seeks to create results while lacking the fundamental understanding of what is actually happening. Cargo cult science is the justification of empirical observations without a true understanding of underlying processes.

 

Part Two: Medicine as a Cargo Cult

By this definition, medicine is a cargo cult science. This says nothing of medicine’s efficacy or its ability to help people, but 21st century medicine is ultimately an empiric science. As much as we understand cell biology and systems physiology, the human body is still an incredible mystery, full of individuality, complexity, and beauty. With the level of current understanding and knowledge, biology (especially human biology) is a black box. As a first year medical student, this is the fundamental challenge in learning medicine – the knowledge gap between physiology and pharmacology.

As much as we understand human organs (the heart is a pump, the kidneys are a set of filters, and etc), with the current level of understanding, it is still fundamentally impossible to deduce the efficacy and the side effects of pharmaceutical agents. We can conceptually think about what happens when we increase or decrease blood flow, but it is still very difficult to determine a drug’s effect given its molecular structure or even what protein it targets. As an example, different approaches are needed to learn physiology and pharmacology in medical school. We want to understand how to body and various organs works in physiology, but we are forced to memorize the characteristics, half-lives, toxicities, and efficacies of drugs in pharmacology.

Yet despite its status as a cargo cult science, I find partial assurance because medicine is an empiric science. We choose what pharmacological therapies to give because it worked for the last hundred thousand people with your illness, and while we might not understand completely the mechanism of its effect, we can be reasonably confident in its efficacy for you. In fact, if you think of it this way, the FDA is the simply the clearinghouse of cargo cult science. The FDA does not simply ask pharmaceutical companies what the mechanism of their drug is (actually it does, but if you follow my logic of medicine as a cargo cult science I’d say that’s misguided.), but actively seeks to test and validate its efficacy.

But more than an effect on clinical outcomes, medicine as a cargo cult has great implications on the speed of medical progress and how medicine will progress in the future. Despite the rapid pace of basic scientific discovery, the difference in attitude and perspective between medicine and science will only widen the gap between scientific knowledge and clinical treatment. The next part will try to explain what I hypothesize will happen and why that is.

 

Part Three: Science Fatigue in Medicine

Unfortunately, it is far too easy for smart people to think of explanations and justifications of what they observe –regardless of whether or not it is true. Anecdotally, I can remember quite a few instances where I was asked to explain a concept, and while I wasn’t completely sure, was able to describe a reasonably sound explanation. Then, in retrospect, the explanation turns out to be completely wrong. Prior to Galileo’s claim that the Earth revolved around the Sun, humans lived normally and comfortably for hundreds, if not thousands of years. Prior to Galileo, there were many scientists, astronomers, and great thinkers – yet were they not troubled with what we now recognize as errors and fallacies of critical thought? Intelligent people, if set in a particular framework of thought, are especially difficult to persuade.

A prime example in medicine would be the recognition that Helio pylori, bacteria in the stomach, can cause ulcers. The scientists were initially ridiculed and scorned – “How can bacteria grow in the acidic environment of the stomach?” – before overwhelming evidence was obtained. It took the efforts of a brave scientist to ingest the bacteria and give himself ulcers before the scientific community could access the truth of his statements. With such a discovery, the entire framework of treating stomach ulcers was changed and Barry Marshall and Robin Warren won the Nobel Prize – but before this discovery, when haven’t other physicians and scientists recognized this link? Hindsight is 20/20, but the question of stomach ulcers is a large part of gastroenterology.

I can think of two main reasons, why medical advancement lags behind scientific understanding. There are undoubtedly more, but I think there are two main causes in relation to perspective and the framework of research. First, medicine works. This gets back to the initial idea that medicine is an empiric science – despite all its shortcomings and gaps in understanding, medicine is highly efficacious and we are at a point in history were previously fatal diseases and symptoms are routinely treated and cured. Just as Galileo was focused on something that seemly had no direct bearing on day-to-day life, many of the problems of medicine are not focused on the day-to-day treatment of patients. If someone has a heart attack, there is a standardized protocol and all in all, it works well. There is a standard of care for most diseases that guide how physicians treat patients. When things work, there is much less of an incentive to figure out why it works and how it works. This is a simplification, but I feel like this especially true when people are overworked, fatigued, and worrying about hundreds of other concerns (such as patients health, regulation, and even healthcare reform).

For the second reason, I would like to suggest a new phrase: Science fatigue. The idea of compassion fatigue is a concept that argues that the media has caused cynicism and lack of initiative in society by saturating newspapers and news shows with decontextualized images and stories of suffering. This inundation of similar images has been cited to cause the public to become cynical, or become resistant to helping people who are suffering – I would argue that this is same case with science. The general public, and physicians in particular, are flooded with so much news of scientific breakthroughs and innovations that seem to never materialize in concrete advances or meaningful change in care. We are always hearing about the latest device and the newest therapy, but the standard of care has changed so slowly that it is difficult to not become cynical about the marketing and showmanship now pervasive in medical science.

 


Part IV: Conclusions

The combination of relative efficacy and inundation of information is especially noticeable in medical education. In medical school, one is expected to learn and understand a large and ever-growing body of knowledge related to basic science and treatment. We are flooded with a huge volume of information – more than enough to occupy us for 24/7 for the next four years – and thus we need to prioritize what is important and what we choose to be curious about. The standard of care is undoubtedly important (medicine first and foremost has to work), so treatment is often emphasized. Science and the basic mechanisms often seem more nebulous and intangible. There are still many aspects of medicine that we do not understand, and the mechanisms we understand are sometimes barely better than the educated guesses of intelligent people. To reiterate, it is far too easy for smart people to think of explanations and justifications of what they observe – and without true understanding of the underlying mechanism, is medicine much better than a cargo cult? With the pressing urgency of patient care and the great body of knowledge expected of every physician, is it possible to function above the level of a cargo cult scientist?

A great clinician once told me that the most important skill to learn in medical school is the ability to deal with uncertainty. When we treat patients, we can never truly be completely certain that our diagnosis is correct or our therapy is the most efficacious. Physicians need to be comfortable with the uncertain variability in disease presentation, drug response, and even human physiology. This uncertainty begins even at the level of molecular mechanisms. Even as basic science pushes our understanding of biology, science cannot be the only force that drives the practice of medicine. Patient needs, cultural barriers, and pragmatic considerations all divide the worlds of medicine and science.

Since coming to UCSF, I have realized that many of the greatest challenges of medicine come not from the science, but from quality of care and from access to care. The most intractable problems of global health and health within our own community come from deciding how and where to deliver care that is currently already available. Healthcare reform seeks to answer the questions of how we can improve our quality of care without bankrupting the economy. Learning to deal with people is an incredibly important issue –  even though we have incredibly efficacious drugs for treating hypertension, asking people to take pills (with noticeable side effects) for a disease that is subtle, often symptomless, is tremenendously difficult. There are many questions that cannot be answered from the benchside and while I still greatly admire and respect science’s ability to alleviate suffering and cure disease, much good can be done in improving the potential we already have in front of us now. For better or worse, medical is truly different from science.

 

 

 

 

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