Rationalism and Empiricism in Modern Medicine
نویسنده
چکیده
About ten years ago, after fellowships and clinical experience in a community setting, I had my first experience as a ward attending in a university hospital. We were working with cardiac patients, and I was struck by the common treatment each patient received. No matter what the symptoms, patients received an exercise treadmill, an echocardiogram, and were put on a calcium channel blocker. This was remarkable at the time because there were in excess of thirty randomized controlled trials showing the benefit of beta-blockers, a different class of medicines, to treat patients following a heart attack. Indeed, by 1990, there was initial evidence that calcium channel blockers not only failed to improve outcomes, but actually made them worse. The point is not to criticize the medical culture at that hospital—similar examples can be found at every medical center—but rather to explore why there was so much fondness for calcium channel blockers. One factor was the substantial drug company support of faculty research on silent myocardial ischemia. Another factor was what might be called medical fashion. The most likely explanation, however, was more fundamental. For my cardiology colleagues, it was biologically plausible that calcium channel blockers were better than betablockers. Like beta-blockers, calcium channel blockers reduce heart rate and myocardial wall stress, but they lack the side effects of beta-blockers. In other words, what was important to my colleagues was not the outcome of the critical trials, but our understanding of the mechanisms of disease. This is an example of the tension between rationalism and empiricism in medicine. Rationalism is the search for and emphasis on basic mechanisms of disease, which then color all clinical decisions. Empiricism is defined as the emphasis on the outcomes of individual patients and groups of patients. My
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