The thrill is gone: the sense of discovery in medicine

The feeling of discovery is one that inspires many people to begin scientific careers. There is a rush of adrenaline that comes with knowing that you are finding something new, you are elucidating mechanisms that were previously unknown or under-reported, you are solving a problem that needs fixing. Discovery brings delight, and can fuel an entire lifetime of work.

To me, as a physician in training, delight has faded to the dull gray grind of paperwork, “getting connected with the right people,” and reading UpToDate articles. My personal ideas hardly play into what I do anymore.

One theme that emerges again and again in the history of medicine is the ability of even junior doctors or trainees, god forbid, medical students, to make important and lasting discoveries. There was the dream of trying to understand the body and its diseases through dissection, late nights at the lab, animal experimentation. I was reading Michael Bliss’s definitive Osler biography, and was struck by his description of the level of diagnostic technology available to physicians in the 19th century:

Doctors had learned to bring all their senses into play in observing living patients. They not only listened to patients’ complaints but looked carefully at their bodies. They learned to feel the bodies, palpating for signs of disease. They took the pulse. They tapped or percussed the chest and back, feeling vibrations and listening to internal echoes. They looked at urine and stool for bleeding and other signs. The sugary taste of urine might confirm a diagnosis of diabetes.

These days, if you suggested that tasting urine were a valid way to test for diabetes, you’d be thrown out!

In the 21st century, the physical exam is overshadowed by more advanced diagnostic images and biopsies and analyses–but that was the standard of evidence in Osler’s time. I think reliance on the physical exam, because of its subjectivity and accessibility to trainees, bred a hunger to understand the mechanism of disease. It was because medicine was so decentralized and case-based that through the examination of individual patients an aspiring physician-scientist could launch a career.

I believe that we still haven’t discovered everything worth naming. And there are still big problems to solve. We still don’t understand how to make 100% use of our brains. We can’t stop people from getting heart attacks. We don’t understand why some people develop diabetes and others don’t, or how to cure autoimmune diseases.

Our tools of discovery are very different than they used to be, and medicine has become an item on the national agenda. Today, it is out with the physical exam and in with precision medicine. President Obama’s recent announcement to launch a precision medicine initiative signals growing public interest in ever-more complex technologies intended to target specific diseases.

However, precision medicine is a falsely new paradigm: while it does offer a new way of thinking about how we deliver healthcare at a social and economic level, I don’t believe that it changes the way we fundamentally think about science and disease which has become defined more and more in microscopic terms, with a focus on genomics, with the same research groups and individuals making the major contributions every damn time. How many non-NIH funded individuals can afford to do “cutting edge” research? How many physicians in training, who are primed to bridge the clinical and research worlds, have the time or ability to embark on autonomous naturalistic and/or wet lab projects longer than 6 weeks per year?

In short, I don’t think that the way we frame “innovation in health and medicine” promotes the ambition of discovery that our medical predecessors had. We cannot access and steer the technology that is supposedly going to revolutionize medicine; instead we will only be users who will have a pre-defined set of applications fed to us.

What we need is something more disruptive, that can inspire students and trainees to pursue creative research. We need more protected time, more transparent methods, frank conversations about the abhorrent funding situation in the US, and mentors who will encourage us to challenge dogma.

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About the friendly intern

Ask a question: The Friendly Intern My personal blog: Pathos and Pathology
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