A patient in pain — trust the scans, or the patient’s story?
It is generally agreed that the practice of medicine is a good idea: but is it based on the wrong science?
Imagine for a minute a patient with chronic pain. An orthodox scientific approach would arrange blood tests and scans, nerve studies and X–rays, scopes and biopsies. We would prescribe evidence-based therapies devised in objective studies such as double-blind trials. We might reassure the patient that we ‘can find nothing wrong’ if these were negative.
However, this account alone is insufficient and now rightly attracts criticism.1
Or we could take a detailed history of pain. What does it feel like? Enquire what was happening emotionally at the time it all started? We could enlist the help of psychologists and counsellors, and acknowledge that only the patient can truly describe their own distress or perceive the nature of their disorder.
This account too, in isolation, is dangerous and limited:2
‘The clinician is expected to approach the patient in a way that is not only scientifically valid and evidence based, but also sensitive to the full range of human capacities, including individual experience, needs and values. These two aspects are typically expected to coexist or merge in the concept of knowledge-based practice, but exactly how such a merger should come about is far from obvious.’3
As GPs, we know that these two accounts are both meaningful and necessary; however, each is incomplete without the other account. Recent debates have highlighted that simplified versions of science can seriously undermine our work. Medicine that overemphasises patients’ perceptions can do likewise.2 This illuminates the potential damaging effects that the lack of an explicit philosophical framework may be having on medical science.4 As Stempsey argues, ‘… a philosophical stance is required even to define a problem as a medical problem’.5 It seems that medicine is adrift between these two polarised views, resting on a weak foundation, even perhaps the wrong view of science.
If our two contrasting pain accounts rest on truth, but cannot be reconciled without appealing to the other, this implies that a third, more fundamental and encompassing account is likely to be more correct.6 To acknowledge this fully we need to do no less than re-think our version of reality. However, I suggest that these changes will feel intuitive and familiar to GPs. I recommend that this should be based on a framework of ‘realism’ in general and ‘Critical Realism’ specifically.
What is a ‘realist‘ view ? — introducing Critical Realism
Engel, in seeking to create the biopsychosocial model, used early systems and complexity theories to provide frameworks for his ideas. However, Engel’s multifactorial idea did not stand on a particular philosophical framework or call for reform of medicine’s over-simplified science.7 This arguably left the biopsychosocial model floating on a sea of philosophical uncertainty.
I want to further the argument that a form of ‘realism’, specifically Critical Realism (CR), is currently the best, and perhaps the only plausible, framework for the human sciences as applied to primary care. CR is already commonly used and recommended in medical research,8 and more widely in other sciences from biology to cosmology. Here, resting on the work of Roy Bhaskar, I describe some of the basic building blocks of CR.6,9
Concept 1 — there really is something that is real. Imagine a world before humanity existed. It seems plain that the general facts of cosmology, the existence of gravity, of matter and the physical properties of the universe were already in place. Biological growth and organisation were present, complex relationships existed between organisms that included movement, symbiosis, and basic forms of communication. Critical Realists believe that science is a process of discovery of an order that pre-dates and is not dependent on humans. The matter, forces and fields, structures, and organisation of this reality are independently ‘there to be discovered’, not just experienced or imagined. We believe that the patients’ blood tests and biopsies represent an important part of reality that does not rest on individual experience or perception.
In philosophical terms this is called a ‘realist ontology’ and GPs will have no trouble with this concept: it is foundational to the basic sciences and is, according to CR, largely correct.
Concept 2 — stratification. CR proposes, and this is substantially accepted in other branches of science, that reality is stratified, rather like a cheesecake. These layers, increasingly complex as we move ‘up’, may bleed into each other somewhat but differ in their characteristics. This is usually represented something like this (see Figure 1):
Figure 1. Stratification of reality according to complexity.
In the basic layers, the natural forms (for example, atoms) and forces (for example, electromagnetism) relate to each other in ways that are somewhat predictable. In more complex layers, the basic physical laws are still present but there are increasingly complex relationships between the basic structures. This complexity is amplified when atoms and molecules form structures such as cell membranes and biological organisms. Extend this to the degree of complexity present in a human being, and it becomes clear that incredibly sophisticated relationships, feedback loops, webs of communicating neurones and neurochemicals exist. This makes sensible or complete explanations, or reductions, in terms of the lower strata, increasingly difficult and often invalid. Stratification indicates that our reduction of a patient to a series of scan images and blood results is inadequate. CR suggests that there is no limit to the number of layers — for example, we could position a ‘society’ layer at the top or a ‘quantum physics’ layer at the bottom, with more to come.
Concept 3 — novel properties occur in complex systems: emergence. Within these complex structures unusual and unpredictable properties arise, properties that are not present in the basic building blocks of these structures or organisms. This is harder for us to apprehend because we may have assumed a fallacy: that larger things can always be explained in terms of smaller, simpler things. Emergent properties arise in complex systems because of multiple non-hierarchical and non-linear relationships between components of the system. The whole is greater than the parts. Emergent properties are easily observable by scientists – for example, the behaviour of a bubble, or a cell membrane. These properties are not present or always predictable at lower levels of organisation. One arguable example might be consciousness, which defies explanation in terms of the simpler components of the brain.10 It is already established that emergence can be a useful and powerful concept in primary care.11
A crucial insight of emergence is the possibility of emergent properties ‘acting back’ on simpler layers of the structure. If we think back to our patient with chronic pain we have all observed how a change in the patient’s ideas can change their physical parameters. If we can convince this patient that ‘pain does not always indicate tissue damage’, we may get them to exercise more, relieving muscle spasm and increasing functional strength: ideas and cognition act back on material reality. In a CR sense, if something can affect the natural order, even an idea, it can be considered real.
Concept 4 — scientists, and science, are fallible. GPs readily accept the limitations of practice: that even the best science can be limited, prone to revisions and error. Sometimes one of our theories attracts so much counterevidence that it has to be completely revised. We hope that our science gets closer to the truth as time goes on, but we can only apprehend science through the limitations of our cognition, language, present scientific instruments, and our interpretation of what their data mean. In technical terms CR refers to this as ‘Epistemological Relativism’ — that our knowledge of truth is substantial, but fallibly observed, and always provisional. For example, future functional scanning of a patient with pain may supersede our present anatomical scans and be more powerful.
Concept 5 — rational argument is worthwhile: Rational Judgementalism. This proposes that the human capacity to reason is not simply a survival mechanism: it is a credible approximation to the truth. A clinical discussion with colleagues from other specialties may well help us manage a patient with pain. Arguments, where well constructed, are important and valid tools in furthering our knowledge. Critical Realists believe, I would suggest in common with most GPs, that all well-conducted research and enquiry can, and should, be acknowledged. CR suggests that these inclusive approaches are valid, but gives us a fresh and robust academic framework to rest them on.
The universe, and the ‘primary care’ part of it, is not linear, predictable, and ruled by deterministic laws that dictate our biological and psychological states. Neither is it a purely experiential one, where the patient’s perspective is the only valid one and can exist without any physical correlation. The patient’s story and their scans are part of one undivided person, and science must bring these together. Critical Realism may show us a way.
