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Siddhartha Mukherjees

The Laws of Medicine

Field Notes from an Uncertain Science

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Table of Contents

The Laws of Medicine: Field Notes from an Uncertain Science is a book that outlines the guiding rules that govern medicine. It is based on the experience of the author, Siddhartha Mukherjee, MD, Ph.D, in the medical field.

When Siddhartha Mukherjee was a medical resident in Boston many years ago, he filled his very tiny amount of free time by reading books about medicine. One of the books he read, The Youngest Science, had a deep impact on him. Before the 1930s, medical intervention was not helpful and its methods were crude. Only when doctors actually stopped these useless therapies and began to actually observe, categorize, and name diseases, was there a revolution in medicine. The profession completely changed and the youngest science was born.

While reading The Youngest Science, Mukherjee began to ask himself whether medicine actually was a science. After all, sciences, such as chemistry and physics, have laws that include statements proven true over and over through observation that can be generalized in every case. Medicine is a soft science with guiding rules rather than hard and fast laws. These rules use intuition instead of tests, pay attention to outliers, and do not underestimate human bias.

Siddhartha Mukherjee: Siddhartha Mukherjee is a researcher and oncologist who writes and speaks about medicine to the public. He is the author of The Emperor of All Maladies: A Biography of Cancer, which won the Pulitzer Prize in nonfiction in 2011.

Dr. Castle: Dr. Castle is a highly competent surgeon and excellent teacher that Dr. Mukherjee observed as a medical student. Dr.Castle taught him about making decisions with imperfect information.

Hermione Granger: Hermione Granger is a character in the Harry Potter series by J.K. Rowling. Granger sees magical laws as a way to understand how to do good in the world, not to do more magic, a concept that Mukherjee applies to medicine.

Lewis Thomas: Lewis Thomas is the author of the book, The Youngest Science. The book inspired Mukherjee to question whether medicine actually was a science, and what the laws of the science of medicine should be.

Mr. Carlton: Mr. Carlton is a patient that Dr. Mukherjee sees during his intern year. Mr. Carlton teaches the doctor a valuable lesson about trusting intuition and using observation to aid in diagnosis.

Thomas Bayes: Thomas Bayes was an early 18th century English philosopher and member of the clergy. Bayes theorem posits that even in the case of probability, knowledge is conditional, not absolute.

Johannes Kepler: A German mathematician working in the 16th century, Kepler was given the task of solving the problem of why Mars looked like it was orbiting backwards, disrupting the accepted model of how the planets orbited the sun. Kepler used Marss exceptionalism to create the theory that the planets orbited in an ellipsis around the sun, which is now accepted to be true.

1. In medicine, doctors often make decisions based on fragmentary information.
2. Modern medicine only dates back to the 1940s. Before then, the choices were amputation, and the three Ps--placebo, palliation, and plumbing.
3. Sharp intuition and observation are much more important than a test that is not very predictive. Tests need to be interpreted with information the doctor already knows.
4. Bayes theorem states that there is no actual knowledge, only conditional knowledge, even in probability
5. Regular cases create a working set of rules, but the outliers prove the laws.
6. Bias is prevalent in medicine, and the problem of bias will only increase with more data.

In medicine, doctors often make decisions based on fragmentary information.

Analysis

Mukherjee observed surgeon, Dr. Castle, working with a resident who was substituting in a surgery for another resident and, therefore, had not read the patients chart. Things started to go wrong in the surgery and the resident asked about the patients history in hopes that it would help him determine how to proceed. Dr. Castle told him he did not need to know the history to proceed. The resident ended up doing a great job.

Imperfect information is a huge problem in medicine. This is especially true in the emergency room. The emergency room presents situations where a doctor has to act much like Dr. Castles resident because the history of the patient is often unknown. This is compounded by the fact that the nature of an emergency forces the emergency room physician to act quickly with little information. At Cook County Hospital in Chicago, doctors wanted to find a way to more accurately diagnose the severity of cardiac events in the emergency room. They narrowed the information they needed to determine whether a patient was experiencing a significant cardiac event to an electrocardiogram and a few clinical predictors that included blood pressure and chest pain. They found that by using this system, they admitted fewer patients into intensive care and all patients got the care they required [1]. Like Dr. Castles resident, in the face of imperfect information they found a way to make smart decisions.

Modern medicine only dates back to the 1940s. Before then, the choices were amputation, and the the three Ps--placebo, palliation, and plumbing.

Analysis

Before diseases were understood, medine usually had a net zero or deleterious effect because doctors did not truly understand what was happening on a physiological level. The choices were to amputate the problematic body part, use a medicine that did not work, offer a painkiller, or purge the body through a laxative or diuretic.

Although there were some advances in how medicine was practiced in the 19th century, such as in terms of hygiene and a better understanding of germs, doctors still did not understand many of the basics tenets of medical science. An example of this is the practice of bloodletting or bleeding a patient, which persisted into the 19th century and even into the 20th century [2]. This practice was based on the idea that disease came from an imbalance of fluid and pressure in the veins. George Washington was bled when he came down with laryngitis and died shortly afterward. Historians debate whether this bleeding was a possible cause of his death. Although modern doctors have found that there are a few specific cases in which bleeding would help, the entire concept demonstrated a lack of understanding of how disease works. In this aspect, medical science was light years behind areas like physics and astronomy, where the basic tenets were hammered out before the turn of the 20th century.