Certainty versus Empiricism in Medicine
Ontario Association of Naturopathic Doctors-Toronto
November 20, 2011
Prelude
You are called at the bedside of a dying child, perhaps your own, who is in the late stage of meningitis with multisystem organ failure and no hope of recovery; a patient who refused conventional approaches after her diagnosis of metastatic malignant melanoma and metastatic breast cancer calls on you; another with life-long “insanity” is asking for what she has never known so far in her life; a pianist comes with Parkinson’s Disease in order to return to his art; a four-year old child with muscular dystrophy who can’t climb stairs anymore; a 23-year old man with heart and liver failure comes after having been told that nothing could be done for him and is distraught at the thought of facing such an early departure; finally two worried parents knock at your door after having just refused hemispherectomy, as a last resort, for their nineteen-month old child with intractable malignant migrating seizures of infancy.
Introduction
Today, I am inviting all of you here present to examine the way we practice medicine. Socrates suggested in Plato’s Apology, “The unexamined life is not worth living.” Similarly, we may say that the unexamined practice of medicine is not worth practicing.
In this examination, we will proceed step by step, and if, at any time, you have any questions regarding the validity of any part of the present discourse, please interrupt me, as anything appearing unsound must be confronted and ironed out at once.
The goal of this exercise is to insure that our approach to health and disease is rational, wise, scientific and effective.
Rational refers to an exposition of principles that is based on sound reasoning and accurate observation.
The practice of medicine is wise when it is safe and holistic, affects the fundamental causes of disease, and uses the different forces and influences of nature to heal in a gentle manner.
Our practice is scientific when we draw principles from observation of nature, apply them and report our results and verifications. Peer-reviewed journals already contain huge amounts of this information.
The practice of medicine is effective when few are the ones who can’t be significantly helped in their health recovery from even the most serious acute or chronic ailments.
Health is a state of balance and harmony that is natural and spontaneous as long as the conditions for life and the needs of the individual are met.
You destroy the environment, you degrade the conditions of life, and you destroy the organism.
All living organisms from the plant and animal kingdoms are subject to departures from normal health in their susceptibility, function and structure. The beginning of these departures is the beginning of disease.
Disease is not a separate entity, as it is commonly suggested by the conventional medical model, i.e., resistance to disease; and it can’t be transmitted from one person to another, i.e., AIDS is a communicable disease.
Disease is a dynamic process in which the force animating the living organism attempts to adapt to adverse forces, influences, or conditions of life. The organism doesn’t resist disease but tries to adapt to the causes of disease and the changes in the conditions of life.
Disease is a multifactorial phenomenon. The causes of any phenomenon are the sum of all the circumstances and conditions preceding that phenomenon.
This clearly implies that physicians must be keen diagnosticians.
The equation of disease looks like this:
Susceptibility + Maintaining and Precipitating Causes and Factors = Disease
At first look, this equation of disease appears to greatly simplify the practice of medicine.
It seems that if we could affect any aspect on the left side of the equation, it would affect the outcome.
This is a very pertinent question when we acknowledge that:
Is certainty in medicine therefore an illusion?
Is there anything on which we can anchor our practice to attain, with certainty, healing in medicine?
Is this the best we can achieve despite more than thirty-five continuous centuries of medical practice and from the observations and reflections of over 140 generations of physicians?
Has certainty in medicine ever existed in the history of medicine?
Let’s see.
Theoretical medicine greatly dominated the practice of medicine, i.e. Hippocrates humors theory dominated medical thinking for close to twenty-five centuries. History teaches that Nature was not charitable at all towards physicians who imposed their theories upon it. The cholera epidemics of the nineteen-century were a good wake-up call.
Empirical medicine, which is as old as theoretical medicine, disregards theory to solely rely on experience for its knowledge, as Nature is incomprehensible and it is fruitless to seek the hidden causes and natural actions.
The scientific approach has since dominated medicine. Evidence-based medicine was born when James Lind conducted in 1747 his trial of using citrus in sailors with scurvy.
The practice of medicine has a huge speculative component, which has been referred as conjectural or empirical.
Ideally scientific medicine ideally, would be strictly based on experimental evidence, and therefore on the exact knowledge of the physiological mechanisms underlying a specific disease process or the therapeutic effect of a drug.
This approach is in essence very practical and characterized by its eclecticism in employing whatever is found to be beneficial to patients, which constantly changes according to last published findings.
As Claude Bernard pointed it out close to 150 years ago, therapeutics that is based on statistics will always remain conjectural.
Our industry-driven modern health care system is characterized by being, reductionist, non-individualized, dysfunctional and plagued with ubiquitous iatrogenesis, general lack of efficacy, exorbitant cost, corruption, overuse, disease mongering, antimicrobial resistance, and pollution of the environment.
An alternative to this is naturopathic medicine as taught in its accredited colleges and practiced by the majority of its practitioners.
I would like to suggest that there is another way of practicing medicine that is most efficacious and effective, which is principle-based medicine.
Incidentally, the word “principles” comes from the Latin “principium,” which means beginning or fundamental truth. I would argue that the principles elaborated below are indisputable and universal, impeccably sound, and are in fact the fundamental principles of classical medicine. “Classical” here means of the highest standards and traditionally authoritative.
The Seven Fundamental Principles of Medicine
The first principle applies to the physician, the actor, while the six others apply to the actual practice of medicine, the acting.
Incidentally this set of principles is universal and can be applied to all aspects of life, especially when it is related to solving problems, whether they are interpersonal or societal, material or psychological, or in the fields of economics, politics, science, etc.
Now let’s apply these principles to practice:
The case in point is the one of a naturopathic physician who graduated less than 10 years ago from one of the two accredited Canadian colleges of naturopathic medicine. Let’s read the beginning of her story:
April 12, 2010: N. H. is a 33-year old naturopathic physician who consults for emaciation related to severe mal-absorption. She has been experiencing right lower quadrant pain for many years, is hungry all the time and has been unable to gain weight despite being on a strict diet. She claims that her problems began in 1995 when she started to have recurrent weight loss. She became much worse in 1997, six months after being in university. She was under high personal stress, including her parents divorce, and began experiencing incapacitating abdominal spasms and has had ever since loose and lienteric stools.
In 2002, she consulted a ND while she was a naturopathic student. She then took a Chinese composite formula called Clear Lungs. She had huge amounts of yellow mucus coming out of her nose and chest for one week. The next morning after receiving a massage at her school she woke up with right-sided swollen face with throbbing. Ever since her right side has been more problematic and remarked that almost her problems have always been right-sided. She has been on a brown rice diet since 2002.
Between 2004 and April 2009, she would wake up with her body hot like a furnace but the bloating was then minimal. If she would have to get up early, like 6-7 am, she would experience nausea the whole day, be unable to talk and have a headache. However it can help to have an hour nap. She is better later in the day, between 8-11 PM. She then has the least pain and can think more clearly. She tends to hold her abdomen with her hands with the pain. She pushes only mildly and the pain reduced from a 7 down to a 4 out of 10. Her digestion and abdominal pain are much worse the week before her periods. As soon as the flow comes, even after the first drop, her energy, mood and pain improve. She is not aware of any other factors that would affect the pain.
The pain doesn’t come suddenly anymore. The first thing in the morning she experiences is nausea, headache, lack of appetite and achy gut. She usually feels as if a truck has hit her. She also feels like a weight in her right lower quadrant, “like a bag of potatoes.” There are no spasms anymore. When she used to get the spasms she would take coffee to alleviate the paroxysms. Appetite comes only 2-3 hours after being up.
Her weight would oscillate between 95-100 pounds but she started to have more problems from December 2008 onward. Within five months her weight went down to 87 pounds. It has since slowly crept up to 91. She must eat every two hours in order to satisfy her ravenous hunger. Her stools have been very offensive, “putrid,” since April 2009. They are reddish, light brown like chocolate milk.
In December 2008, she began having more stress in her relationship and at work where she was putting long hours (50 hrs/week). By April 2009, she became exhausted, at which time she developed more intense abdominal pain. She decided to cut her office hours, but it made no difference. She tried many different approaches but in vain. In June 2009, she began looking for outside medical attention. She had a textbook case of celiac disease and was found out to have eosinophilia. She cut out all gluten-containing products from her diet. It made no difference.
She realized that she had been constipated all her life. As a child she had hard stools accompanied with bleeding every 2-3 days. The stools are now daily but loose. From June until December 2009, she used enema to move her bowels. In July she saw another gastroenterologist who conducted more tests, which were inconclusive, as she was positive for antigliadin IgG but negative for IgA.
In August 2009, she left her abusive relationship and consulted a high profile ND who conducted food intolerance testing and told her to avoid gluten, eggs, soy, corn, potato and dairy. She felt much better. She felt less hypoglycemic and the spasms disappeared but not the pain. In November she was diagnosed with giardiasis. She took flagyl (metronidazole) and felt much better and had no pain for the first two or three days only. She then began experiencing the side effects of flagyl and went downhill afterward.
In January 2010, she began seeing an energy healer every 1-2 weeks. She was told that she had a bowel infection from water borne organisms acquired in her childhood that was destroying the mucous membrane and she had “holes in her intestines.”
Since April 2009, she has been experiencing right lower quadrant pain of a gnawing character. All the right side of her abdomen is sensitive to touch. She first experienced this pain in 1997. It first came suddenly and lasted for a few hours. In April 2009, it also came suddenly and lasted only one hour. But then it soon relapsed and stayed until now. This pain is worse in the morning. She is worse the first hour after waking, the earlier the worse she is. The pain comes once I am out of bed. She wakes up with tons of gas.
She also has right ovarian pain. She has pain going down her right lower limb along the gallbladder meridian, which is better from rubbing (2) the leg only and not the lower abdomen. Her right lower limb has always been heavy, achy and tingling since January 2010. She has joint pain in her right lateral inner knee. It is an excoriating pain. It is tender around her right patella. It is better with pressure of the hand (1). Her father broke his right patella in three different occasions.
She complains of right arm and right leg heaviness while her left side feels light. She has right-sided headaches which are better from pressure (1) and cold applications (1). She has an aversion to warm applications. Her right gums are ear are achy. She never has any problems on the left side. Her headaches have been daily for the last three months. They are localized in her right temple. Her right eye feels heavy. She holds her head a lot (2).
She experiences constriction of her right chest, which is tender to touch and the pain extends down her right arm. At 12-13 years old, she was training for tract and long distance swimming. Now she can’t even run without experiencing SOB and palpitation.
Her right ear clicks, as if it was plugged. “I bore my finger in my ear all the time.” She remembers getting sharp shooting pain in her ears in airplane as a kid. Now she gets motion sickness when the plane is landing. She has had strabismus for five years
Since a “detox,” she has had chronic cervical and inguinal lymphadenopathy. She has six nodes along her sternocleidomastoid muscles and three in her posterior cervical area. The inguinal nodes are hard. She had severe condylomata in 1999-2000. There were removed over a period of two years with cryosurgery. “They were so hard.”
In 1997, she started to experience panic attacks. She had been fearless prior. She travelled by bicycle. In 1997, a man came into her apartments and held her hostage. “He would hold me down wanting me to scream.” She refused to be upset by it. She was very intellectual. “How do I get out of this.” She is never violent.
She has never been well since her board exams in 2004. She crashed and never recovered.
She cries about five times a week, particularly when she writes her journal. She feels more sad and lonely when the sun goes down (2). She has been emotionally worse in the last 6 months. She realized that she has been sad since 1997. “I am lonely. I used to be very, very shy and reserved. I am the youngest of three siblings. We are all four years apart and none were kind to me. I was always worried to say something wrong. I did a lot of activities, ballet, sport, piano, working at the library, etc. I didn’t have much friends in school. I was always alone. I would go out alone. I would go out because I was lonely. I could feel the void of friends. I love to dance. I would go out at night to dance, but not for coming back home with someone.
Her next menstrual period is expected in two days. She now experiences right ovarian pain.
She experiences extreme fatigue. Her energy is only 4-5 out of 10. When she became tired she became more active. Now she is worse from exertion (2) and feels better to just go to bed and rest. Her energy is better by just talking to people (2). “I feel amazing.” However as a kid, she rarely got involved in conversation. When she is anxious or sad, she plays boring games, like solitaire, to keep her mind busy. As a kid she loved doing monotonous activities. Once she counted to 720, shooting the ball on the wall with a tennis racket. She feels better by keeping herself busy (2).
She has high performance anxiety, i.e., before meeting patients. This is one of the reasons she used to drink.
Past Medical History:
In the fall of 2008 and winter 2009, “I had been very much in love since March 2008 and I was now grieving.” She has a family history of alcoholism.
Past Homeopathic Treatment:
In 2002, she was prescribed Carcinosin 200 at the clinic of her naturopathic college, 3-4 doses without much improvement. In 2003, she was prescribed also in the clinic at her college Falco peregrinus 200 (proven in 1998). She became less irritable ever since, unless she is hungry. Also she has not been able to drink alcohol ever since. The day before she could drink 4-5 gins. One month later she was given the 1 M potency but there were no further changes. She took many doses of Silica 200 and 1 M with some improvement, especially in becoming less anxious. Whenever she takes Silica her hair become thicker. She took on her own Ignatia 200 without any changes. She never experienced any aggravation after a homeopathic remedy. To the contrary she experiences a high as a rule. Similarly she is very sensitive to acupuncture.
She has been taking Silica 6 X for the last two months, since a right ear infection. She has since experienced a mood shift for the better. “I had low self esteem, but I was courageous to travel and to open a clinic on my own. I am a monomaniac. I am very conscientious about trifles and this has improved since Silica. I had so much performance anxiety.” She challenges all her fears. Her self-confidence is more about certain things and less about others. It is 8 out of 10.
Physical General:
T.: She is very thin and very chilly. Her hands are cold (2) even in the warmest of weather (35?C and above). She wears sweaters even at 26?C inside her apartment. She even goes to the beach all dressed up. She loves sitting in the sun but not baking in it. She has enough of the sun after 15-20 minutes. Her sister is the same. She is not affected by storms. She loves the rain. She doesn’t sweat much. However, she sweats when talking with patients. She then has an offensive odor from her axillae. She has always had a bad breath, and especially worse in the last 6 years.
She likes the fresh air and she can’t properly in a warm room (2). However, she keeps her apartment at 26?C in the winter but keeps a window open or keeps the fan on.
Sleep: She has difficulty falling asleep because her best energy is at night. She goes to bed at 12-1 am. She has a history of grinding her teeth at night during stressful time. She has an aversion to have warm feet in bed. She sticks them out about twice a week since at least 1997. She sleeps on her abdomen (2). She doesn’t sweat at night. She wears light clothes with heavy covers. The temperature of the room to sleep in is not important. She doesn’t remember her dreams.
Appetite: She has a poor appetite. Even if she would feel hungry the pain is associated with nausea. She becomes full easily ever since childhood (3). She likes crunchy food, like corn chips. She feels better after eating red meat (1). She has had beefsteak daily in the last 2 ½ months.
She has never had a good relationship with food. She never ate breakfast, would vomit lunch and ate only a few bites for dinner. She would be hungry a few hours after dinner. She is highly sensitive to sugar (2). After only one jujube, she has a headache.
She has been thirsty all the time since 2004, but doesn’t think of drinking. If she does, she drinks ½ liter at the time. She gulps it every time, making swallowing noise in her throat. She observed that it is characteristic of her of not attending to her needs.
Menses: She had her menarche at 16. She has one week of PMS characterized by sadness with aversion to consolation (2), right ovarian pain and constipation. Her sexual desire was not very high until she reached her 30’s.
Sensitivity: She describes herself as being very sensitive, especially to others reactions and moods. “I can feel others’ feelings.” She was the one to console others in her family. Her parents separated in 1997 and she took care of them separately. “I am always there for others. She can’t watch the news (2), she gets sick and has nightmares. She has not watched TV until this year. She likes the binding of clothes (2), like turtlenecks. She wears tight pants.
“I would go out at night because of lonely desperation. I tend to feel guilty (1.5).” She tends to be impatient, i.e., waiting in line (1). She has been anxious all her life (3). She worries whether she will ever have a family. She is not a very envious or jealous person. As a kid she had fear at night, fear that somebody was in the room. She would freeze with fear, thinking that if she didn’t move she might not be noticed. This was much present until about 12 years old.
As a kid she was afraid of saying something wrong and it is still there. “I fear I will not find the right word, especially if I have to defend myself.” This seems to have improved in the last two weeks.
Stress: Everything is stressful for her, but the worse stress is around relationship with men.
Trauma: 1) The last year.
2) 1997: Her parents separated and beginning university.
3) 2005: establishing her practice.
Objective Symptoms: It was discovered by US that she has a small hemorrhagic cyst in her right ovary. She has had mild acne since her 20’s. All her nails have ridges. It started with her thumbs when in naturopathic college. She has very strong nails and very good teeth. She has never had any cavities. She has a wide but superficial crack in the middle of her tongue. Her tongue is indented with a white coating. She has developed a yellow fungal nail on her first right toe over six months ago. She did a CDSA in 2007 that was negative and in 2009 she did a conventional stool test that was also negative. She has had endoscopy, colonoscopy, CT scans with contrast, capsule endoscopy, … without any diagnosis.
Assessment: It is a clear case: Feeling forsaken, heaviness of the abdomen better from holding it, heaviness of the body worse right side, gnawing pain in her right ovary, timidity, lump in the rectum, chest pain extending her right arms, worse form the warm room, general amelioration from pressure, the binding of clothes and rubbing, better from exertion, being occupied, desire to talk, fear to say something wrong, uncovering her feet, desire for meat and worse from consolation.
Plan: RX 200 C, one dose.
End result: Since April 2010 until October 2011, this patient experienced a continuous recovery of health, with many return of old symptoms and improvement on all levels, such as greatly increased energy, disappearance of the abdominal pain, return of heat to her body, happiness returning, normalization of her appetite, digestion, stools and weight, etc. Soon after initiating treatment she had her first formed stool in over a year, and she wrote, “this is a BIG DEAL!” She was able to resume vigorous activity, like one hour of tennis, “when we started it was a struggle to just walk to my car.” By October 2010, she wrote, “Overall I am doing fantastic! I am having a feeling of disbelief and thinking to myself: I never knew life like this was possible.” On year after the first dose, she had gained 8 pounds back to 97 pounds, and “mostly anxiety, sorrow and pain free.”
She was seen only once in the office while all the visit were with email reports and exchange on the phone, as she lives close to 1500 miles away. As you can see it is very environmental friendly.
(Post-script note: Her health continued to improve by leaps and bounds on all levels. When she was first seen she was exhausted by just walking to her car while she can now exercises regularly at the gym, and has plentiful of energy. May 2013)
If such result was a rare exception in practice, of which one was boastful about then we could then be sure that there is no certainty in medicine and continue to hope for the occasional success like the blind hen pecking for food.
However this is not case as I can testify when the above principles are meticulously abided by, certainty in medicine becomes a reality.
While preparing this lecture I looked at my schedule for a period of three consecutive weeks and the great bulk of the cases I scheduled have one of the following conditions or their sequelae:
What all these cases have in common? All have poor prognoses from authorities in conventional medicine.
Why do these patients knock at our doors? Partly because they are failures of the conventional model and because we offer sound alternatives with true opportunities for the natural recovery of health.
It is interesting to note, that the great majority of these patients experienced a recovery of health that is predictable, quick and long lasting, and this despite the fact they were seen only once in their life, as they are treated long distance after the first examination.
The naturopathic profession abides to certain fixed fundamental principles of medicine. However, similarly to conventional medicine, its practice is a far cry from these fundamental principles. Conventional medicine has an excuse, as it is said to have no philosophy. Naturopathic medical students are either not receiving an education that reflects the ideals and state of the art of the profession or once in practice they stop abiding to them.
Samuel Hahnemann said before his colleagues in Paris in 1835, “When we have to do with an art whose aim is the saving of life, any neglect to make ourselves masters of it becomes a crime.”
What shall we think if only a very small number of graduates of dental schools could successfully practice the state of the art of their profession? What shall we do when only a very small number of graduates of naturopathic medical colleges are able to successfully practice the state of the art of its profession?
I hope I have clearly emphasized the importance of first, addressing the fundamental causes of diseases, namely the susceptibility and/or the many maintaining and precipitating causes and factors of diseases, and second, to encourage the innate regulating and healing force of life by making sure that the conditions of health are met and by using, if necessary, the help of the various outer forces and influences of nature to enhance the recovery of health.
In his Ars longa, vita brevis, iudicium difficile, Hippocrates lamented that judgment was always a difficult task, as life appeared too short to enable the physician to master the art of medicine. However, when medicine is practiced according to its most fundamental principles it becomes rational, wise, scientific and effective. Recovery of health of the whole person is therefore gentle, rapid and durable. Certainty in medicine becomes a reality, the sick ones don’t suffer unnecessarily, and physicians fulfill their mission.
