We're not teaching medicine well

Epistemic status: Slightly provocative title, emerging hypotheses, rant-heavy

Written with: Akshay S Dinesh

Inspired by: A set of tweets by Akshay

If you’ve been active on Twitter or following debates around masking in newsrooms in India, there’s a common refrain that is being screamed from the rooftops- “Trust the experts”. Across all domains of research and discovery, we see an increasing attempt to gatekeep systems of science, critique, and understanding.

• Whose opinions do we listen to?
• How credentialed are they? What suffixes do they add to their names?
• Where do they work?
• What is their professional training? Is it only in the social sciences?

In a recent heartfelt essay, Ayurveda professor Kishor Patwardhan called out existing knowledge practices in Ayurveda, drawing attention to the gaps in old textbooks, and the need to consistently question what we hand down as accepted knowledge to future generations of practitioners. His plea is a sincere effort to reshape and reframe institutionally solidified approaches to education in Ayurveda. He says, “We must not hesitate to put our practices through scientific scrutiny. The scientific attitude is universal, and it cannot change from one stream to another.”

An inability to critically engage with existing knowledge is not a bug in Ayurveda alone, but rather, a feature in how we approach medicine in all forms.

Who is allowed to ask questions?

In India, doctor worship is the norm. Often driven by the asymmetry of information, medical practitioners often adopt a paternalistic attitude in working with patients. Rarely is context provided, and if there are questions, medical practitioners swat them away, an inconvenience unworthy of their time and expertise.

Take an example of typical medical services delivery. When it comes to asking patients enough questions to capture detailed history, many t practitioners simply don’t do enough. In a paper by Georgetown Health Economist Jishnu Das, he examines the quality of patient advice in India in public and private settings, revealing some shocking numbers. “In the private sector and in public hospitals, the amount of time spent is fairly low relative to other countries. In public clinics, however, the situation is disastrous. In these clinics, representing about one-third of the visits that we observed, the average number of questions asked was one (and that one was often asked rudely).

It is not uncommon for patients, families of patients, and even junior doctors to feel like they do not have the space or the power to ask for more information, evidence for advice that is offered, and the rationale governing key medical decisions. While there is absolutely an argument to be made for the time and resource constraints of doctors in heavily crowded, overburdened clinics, this paternalistic attitude toward the medical system is coded in our culture.
Often, we simply do not trust patients to know what’s best for them and declare them incapable of making complex risk-benefit analyses. In our efforts to dole out the ‘right’ medicine and the ‘right’ diagnosis as quickly as possible, we do not spend enough time empowering families to make difficult decisions, trusting them with the agency and knowledge they need to support patients. If we intend to practice patient autonomy as a guiding principle of how we run our healthcare system, trust is a key component of this social contract that we simply cannot afford to deprioritize. Trust cannot exist in a vacuum, nor can it exist only in a single direction.

“Trust the doctor, trust the system, trust the evidence”. Do we stop to trust the patient?

Can we really trust the evidence?

COVID-19 has exposed serious gaps in the evidence pipeline. The existing medical infrastructure simply is not prepared to deal with the reams and reams of so-called evidence that are produced on a day-to-day basis. Healthcare providers received the short end of this stick. Apart from putting in hours every single day in full protective gear, and watching hospital beds fill to the brim, doctors were also expected to quickly decipher protocols, medications, and triaging procedures. This is not a fair expectation to place on an already weak, stretched-thin population.

Take the example of the drug, Ivermectin. In a fascinating case study of human behaviour, the people pushing the use of ivermectin have almost reached a cult-like status. There is an incredibly coordinated campaign that claimed the lack of widespread adoption of the low-cost anti-parasitic drug was akin to a human rights violation. In response to well-intentioned scepticism, doctors discussing protocols online often received tens of research papers pointing to clear success in using ivermectin in COVID-19 protocols. In fact, people are often willing to put themselves in legal trouble to spread the message of the secret drug. Take the case of Arkansas in the United States, where prison inmates were given Ivermectin without their knowledge or consent. They were told the pills were vitamins.

The stories are so bizarre that you start wondering if there can be so much smoke without a teensy bit of evidence-based fire. The reality is that there is little to no evidence to support the use of ivermectin. In July 2021, a systematic review by Cochrane Collaboration — an international academic organization that does evidence reviews to inform clinical practice conclusively showed that Ivermectin holds no place in our quest to treat COVID.

Unfortunately, well-run studies have often been overshadowed by fraudulent and poorly done studies that are either entirely observational or on sample sets so small that they would not make it past any scientific scrutiny. Many papers have since been retracted or debunked, but the damage has been done, and doctors are not immune to this damage.

Uttar Pradesh was the first state in the country to introduce large-scale prophylactic and therapeutic use of Ivermectin. In May-June 2020, a team at Agra led by Dr. Anshul Pareek administered Ivermectin to all RRT team members in the district on an experimental basis. Multiple headlines claimed that UP’s success could be attributed to the widespread and prophylactic use of ivermectin. Hindsight is a gift. We now know that Ivermectin adds little to no value to treating COVID-19. We also know that work done by independent journalists and the non-partisan group Citizens for Justice and Peace shows that Uttar Pradesh is “one of the hardest-hit states” in the country with the “weakest” death recording, it said, adding that multiple testimonies from residents to the JCP team appear to corroborate the data. Ivermectin and Uttar Pradesh are not exceptional, and we’ve wasted plenty of time trying to understand why they were exceptional, instead of questioning the body of evidence that now seems so spurious.

While COVID has exposed major gaps in the knowledge-making processes in the medical system, it has also shown what is possible when healthcare workers come together to question the system. Since March, a group of volunteers in Kerala have trawled local papers and news networks for reports on deaths due to COVID-19. In the early months of the pandemic, by Dr Arun N Madhavan, a general medicine physician, a group of volunteers in Kerala checked daily newspapers and news channels to record every single death reported in these sources. They took notes on every death reported in the news and obituary notices and diligently entered the details in a spreadsheet. While this is a heavily low-tech solution, these doctors were the first to call attention to missing COVID-19 deaths, leading to a wave of excess mortality calculations in India. Driven purely by a pursuit of the truth, these doctors began a large movement that has now led to international scrutiny of COVID-19 evidence in India.

Where did we go wrong? How do we mainstream critical thinking in medicine?

One of the most basic tenets of the scientific approach is in the questions we ask and the questions we believe we are allowed to ask. A culture of healthy questioning is essential to the robustness and high standards of medicine. As an institution of health care providers, modern medicine can do better in encouraging a practice of asking questions - about the evidence we rely on, the decisions we take for our patients, and our own missteps along the way. It is just as important to encourage questions from the people we work with, be it our patients, colleagues, students, or simply concerned internet trolls.

For us to tighten the string on what we call evidence, credentialism cannot become a substitute for rigour. Hierarchies while useful for management cannot supersede the agency to ask questions. In a way, our institutions have coded for healthcare providers to be antagonistic to questioning their beliefs, methods, and practices. It often puts healthcare workers on the defensive when questions are only asked to assess malpractice and to assign blame. We need to get better at creating an atmosphere where questions lead to better answers, lead to better, iterative practices, and lead to happier, healthier patients and doctors.

This egalitarian outlook must also be extended to patients and other professionals. The principle of autonomy and self-determination arises from human dignity. A shift from “I know better” to “Nobody knows better” is required to allow this in practice. This shift also makes the practice of medicine less paternalistic and instead more empathetic, considerate, and collaborative.

The medical establishment is also not immune to the challenges of perverse incentives created by greed and self-centeredness. This makes us seek comfort in the ladders of academia where we use the motto of ‘publish or perish’ to choose to ‘publish’ whether or not rationality is involved. We can similarly be seen enjoying the luxuries of a growingly corporatized health industry where rationality and people’s health are again sacrificed at the altar of profit margins and business efficiencies. These perverse incentives have to be dismantled structurally.
An argument can be made that the origins of these problems can be traced to lower levels of education. That we do not do enough in our schools to build a foundation of critical thinking. Medical education is just carrying forward this innumeracy and overconfidence. We need to bridge these gaps and build critical thinking capacity in our education systems - higher or lower, as the case may be.

The authors are well aware that a call for rationality and scientific thinking is often construed as a narrow-minded and arrogant pursuit of science by some sections of the readers. We see these as responses to the reality that in our systems science and humanities are often practised as opposites. We have to recognize that this dichotomy is not the only way it could be. Therefore we shall not be asking for “humanities'' or “sociology” as elective courses in medicine. We should ask that medicine continue to be rewritten to adopt humanistic lenses as we continue to fight for rigour, evidence, and healthy scientific debate.

This is not impossible work. This is hard work, and it often begins with being brave enough to do the right thing - to question.

References:

1. Das J, Hammer J. Money for nothing: The dire straits of medical practice in Delhi, India. Journal of Development Economics. 2007 May 1;83(1):1–36.
2. Popp M, Stegemann M, Metzendorf MI, Gould S, Kranke P, Meybohm P, et al. Ivermectin for preventing and treating COVID‐19. Cochrane Database of Systematic Reviews [Internet]. 2021 [cited 2023 May 11];(7). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015017.pub2/full
3. India coronavirus: How a group of volunteers “exposed” hidden COVID-19 deaths. BBC News [Internet]. 2020 Nov 20 [cited 2023 May 11]; Available from: https://www.bbc.com/news/world-asia-india-54985981