Tuesday, April 19, 2011

Emperor of All Maladies: Lesson Two [Cure doesn't require understanding]

Sidney Farber (born in Buffalo NY!) comes off as almost God-like in his devoted and capable assault on childhood leukemia in Mukherjee's prose. He has a fantastic quote:

"We cannot wait for full understanding; the 325,000 patients with cancer who are going to die this year cannot wait; nor is it necessary, in order to make great progress in the cure of cancer, for us to have the full solution of all the problems of basic research." 

Clifton Leaf highlights this point in a 2004 article "Why We're Losing the War on Cancer--And How to Win It"

"Indeed, the cancer community has published an extraordinary 150,855 experimental studies on mice, according to a search of the PubMed database. Guess how many of them have led to treatments for cancer? Very, very few. In fact, if you want to understand where the War on Cancer has gone wrong, the mouse is a pretty good place to start."

I contend this points to a disconnect in medical education. Medical students devote much of their spare time, their aspirations, and their tickets to the upper echelons of their chosen field to laboratory research. Or, in a word, to understanding disease. A heavy focus on understanding overshadows the need for tinkering, tweaking, trial and error. Or, in a word, to engineering a disease solution.

A few esteemed authors who advocate engineering are Matt Ridley and Aubrey de Grey. In "The Rational Optimist," Matt Ridley describes how the inventors and refiners of the steam engine knew very little about thermodynamics. In "Ending Aging," Aubrey de Grey describes a novel approach to degenerative disease that focuses on allowing damage to occur. He simply endorses cleaning it up faster than it accumulates. (I deeply, deeply urge you to make 18 minutes to watch de Grey's TedTalk. Please.)

I think the major problem with engineering solutions to diseases in the medical sciences is that it necessarily entails making mistakes and being wrong. In Kathryn Schulz's incredible "Being Wrong," she outlines the virtues of embracing the practice of making mistake after mistake after mistake in order to reach true progress.

Wronghood is verboten in the medical world, causing medical students to cower in fear. Pursuing quiet, removed understanding in the laboratory is vastly preferred. Yet the removed nature of these pursuits hamstrings the connection of this understanding to disease solutions.

Engineering begins at the source of the problem and proceeds in dumb stubbornness, but when it works, it works immediately on the problem without the need to be translated from a published text to a point of care intervention.

Somehow, we need to figure out how to free medical professionals to be wrong in a safe but productive way. Then, as Farber said, we can get solutions to patients without necessitating the added effort of first understanding.

I propose medical students can start by attempting quality improvement initiatives on the floors. Students could query the clinicians about aspects of workflow that are difficult, and then pursue avenues to streamline them. These are essentially engineering challenges, and success directly and immediately translates to patient care.


Anne Marie said...

I very much agree that we need to get medical students questioning and sharing their ideas from Day 1. I've just been thinking tonight about 'informal learning environments' - wouldn't it be great if on each placement you could connect to others in the same ward/hospital/speciality as you and start sharing your learning. Staff could sign in to and join in the discussions. Thank you!

astupple said...

Yes! We could have a twitter button right in the EMR!

I wrote a proposal for fourth year med students blogging about the clinical relevance of first and second year classes.

Maybe involve the platforms of sharing into the curriculum, and then they won't be able to help themselves from sharing?

Thanks so much for reading.

mohit said...

Must be an enjoyable read The Emperor of All Maladies, A Biography of Cancer by Siddhartha Mukherjee. loved the way you wrote it. I find your review very genuine and orignal, this book is going in by "to read" list.