The Intellectual Crisis in Clinical Science: Medaled Models and Muddled Mettle

THE INTELLECTUAL CRISIS IN CLINICAL SCIENCE: MEDALED MODELS AND MUDDLED METTLE ALVAN R. FEINSTEIN* Amid the many problems in cost of care, distribution of manpower, ethics of abortion and euthanasia, and other crises of modern clinical medicine, another important problem seldom receives attention. The additional crisis, which is the subject of this essay, is intellectual. It arises from the conceptual models used in clinical thinking. At any era in the history of medicine, clinicians have relied on certain basic ideas to act as theoretical models for reasoning about the manifestations , cause, and treatment of disease. Although seemingly satisfactory during the era in which they were used, most of the models were later found to be defective. Some were overtly wrong; others were superseded by improvements brought from advances in science and technology . For example, the basic model of humoral derangements served for many centuries as a theoretical concept that united the cause and treatment of disease. In that model, disease was caused by imbalances in the four humors of blood, phlegm, black bile, and yellow bile. The imbalances were rectified by appropriate treatment with bloodletting, blistering, purging, and puking. In modern medical activities, a different set of conceptual models has been developed for ideas about the diseases, decisions, and data evaluated by practicing clinicians and for beliefs about the goals and basic sources of clinical science. Like the well-established concepts of the past, many of the current models have been "medaled" by their widespread acceptance and general popularity. Yet each model has some outstanding defects that will require major improvements for clinical practice to Supported in part by the Robert WoodJohnson Foundation grant 6309 and the Andrew W. Mellon Foundation. The opinions, conclusions, and proposals in this text are those of the author and do not necessarily represent the views of either foundation. *School of Medicine, Yale University, 1-456 SHM, P.O. Box 3333, New Haven, Connecticut 06510.© 1987 by The University of Chicago. AU rights reserved. 0031-5982/87/3002-0520$01 .00 Perspectives in Biology and Medicine, 30, 2 ¦ Winter 1987 \ 2 15 deal successfully with its current and future challenges as a humanistic science. My purpose in this essay is to discuss the models, the defects, and the improvements. 1. The Basic Sources of Clinical Science Until the beginning of the nineteenth century, clinical medicine was regarded as a basic source of fundamental scientific challenges. The challenges had explanatory goals: to understand the disordered structures and functions that were mechanisms of human disease. In pursuit of the explanations, scholarly clinicians left the bedside to investigate pathologic anatomy in dead human bodies, physiologic abnormalities in experimental animals, and chemical or microbial phenomena in various laboratory arrangements. As knowledge accumulated and opportunities increased, four new scientific domains—pathology, physiology, biochemistry, and microbiology —evolved from their basic sources in clinical research. With further development during the first half of the twentieth century, these new domains became separate "preclinical sciences." Each domain contained a mixture of concepts, some coming from direct exploration of clinically oriented questions, others arising nonclinically in work of the domain itself. After World War II, the funding for this type of clinically derived research was sharply increased; and the research changed its orientation . The preclinical sciences became detached from their clinical origins and were converted into "basic biomedical sciences" with goals that often no longer aimed at mechanisms of disease, with investigators who often had no clinical training or responsibilities, and with results that often had no overt relationship to clinical phenomena. The maintenance of a clinical connection for the new activities was assigned to clinical investigators . Well supported and abundant at medical schools, the clinical investigators learned the advances of the "basic sciences," tried to apply them in suitable research with patients, and taught the "basic" scientific ideas as correlated explanations for the mechanisms of human disease. The magnificent achievements and benefits that have come from basic biomedical science are beyond dispute, but the new orientation led to several unanticipated problems in clinical medicine. One major problem , to be discussed later, is that the new scientific models, despite their splendid contributions in explaining the pathophysiology ofclinical phenomena , were not pertinent for the managerial issues...