It's only fair to share…

The selection criteria, has changed a bit over the years but medicine still draws from the most intelligent members of society.

However, there are different types of intelligence, so what I am about to say next comes with the obligatory (albeit pathetic) trigger warning. To get into and pass medical school, get into and pass a post graduate program trains doctors to regurgitate information. Yes, clinical cases require thought, but ultimately, doctors are rewarded for remembering and repeating what they have been taught. As a doctor I can say that medical education does not encourage original thought or the questioning of those who regard themselves as being “above us”.

This is not a criticism of medical education per se. It is endemic in medical culture and not particularly new. The story of Ignatius Semmelweis should be compulsory reading for all doctors. His discovery that washing hands before delivering babies after leaving a mortuary would reduce perinatal infection was rejected by the establishment of the time. His days ended tragically.

This couldn’t happen in the modern era though – surely. Barry Marshall who discovered the helicobacter  to be the cause of ulcers was not warmly embraced either and was ridiculed. A Nobel Prize silenced the critics – twenty years later.

And today? How interested is the profession in findings that challenge the existing world view?  Especially when that view does not conform to the ideology of big public health. When a patient defies the odds or reports benefit from some action they have taken is the thinking – that is interesting. What if it could be reproduced? Wonder what the mechanism might be? Or is it dismissed as an anecdote lacking the “evidence” of a double blinded randomised placebo control trial?

The two are not mutually exclusive. There are various types of evidence including real word data and what is increasingly being described as “the lived experience”. This is where what happens to real people in the real world clashes with the trials conducted in ivory towers using rarefied populations.

There are two areas where this has sparked my personal interest. The first is in Medicinal Cannabis. As medical advisor to Little Green Pharma, I have seen first-hand people who got significant benefit (and of course, those who have not). Nothing works for everyone. However, when a patient with MS says that he no longer uses a walking stick after being on Medicinal Cannabis there are two options. One is to deny what he says as clearly, he lacks evidence. The other is to be curious and wonder whether if it can happen once , maybe it is possible that it can happen again. It might even spark interest to do a study.

The other area where lack of curiosity abounds is in the management of obesity and type two diabetes. In the 1970’s there were few people with this condition and not that many who were overweight. The major change since then was the adoption of low fat dietary guidelines.

It took science writers like Gary Taubes (a physics major) and Nina Teicholz to point out that insulin drives these problems. Insulin release is driven by carbohydrate consumption. The more we consume carbs, the more we release insulin and so it goes.

But ignoring that, what if a GP somewhere had a 50% reversal or remission rate in patients with Type two diabetes and was reducing their medications. Should this be dismissed as lacking evidence or make us curious as to how it happens and if we could emulate it?

UK GP Dr David Unwin achieved this result by having his patients follow a low carbohydrate diet. Many also lost weight, had improved liver function and lower blood pressure. Oh dear – the dangers of defying “best practice”. I encourage you to watch his Australian presentation. He listened to a patent and was curious!

The conflict between real patents and “guidelines” is getting starker and should cause all health professionals (not just doctors) to challenge our beliefs. Those clinicians who see the real end results have become (forcibly at times) subservient to ivory tower overlords who see data and rarely patients but who impose their views on everyone.

The problem of the public health guideline driven, tail wagging the clinical dog is best described by Richard Horton in the Lancet “Public health today is crudely reductionist, often ignoring or denying the lives of those it purports to defend. Public health has evolved into an elitist endeavour, more concerned with its own power, reputation, and survival”.

New year is a good time for reflection. Let us all resolve to be more curious in 2020.

A version of this article first appeared here.