Medicine – Science or Art?

Having just read the results of the CREDO-Kyoto trial published in the American Journal of Cardiology, I am once again struck by the question, “Do we practice Medicine as an art or science?” The trial explores statin use in specific patients with severe kidney disease. The findings – statins do not help these patients. Still, I know no doctor who would withhold statins from such patients, as they are arguably the single most advantageous drug of the last decade. We doctors (and I, a cholesterol specialist and cardiologist) believe statins to be beneficial even when the data are lacking under specific circumstances such as the one cited above. The reason for our almost jingoistic attitude resides in the fact that the mechanism of statins’ action simply makes sense to us. Statins act on so many levels to thwart heart disease development and progression. They lower LDL, decrease clotting, and diminish inflammation… This in concert with our tacit understanding that trials are imperfect enables us to reach beyond black and white science into the arena of scientific reasoning. This leap might be considered by some to be more akin to art than science, but I’m not so sure. Science has been pigeonholed into a tightfitting yea or nay realm. Although we think of science as true or false, real medical science builds and tests theories derived from biologic understanding. And real medical practice cannot and should not wait for every iteration of every clinical scenario to be studied. Were we to wait for that, we would never treat a single patient. After all, no one can dispute the fact that each human being is different. Through epigenetics we understand now that even identical twins are not identical! But let’s look at a similar clinical study situation with a diametrically opposed outcome.

We know that high Homocysteine levels correlate with cardiovascular events – heart attacks and strokes. This understanding led to a series of outcome trials to evaluate the lowering of Homocysteine with three B vitamins. Some trials showed benefit while others did not. Of course, each trial had its own pitfalls; that is always the case. With Homocysteine however, doctors responded differently, claiming there is no need to treat this problem, no matter how compelling the scientific premise. Here, I believe we erred. Some studies cited as negative tested the same population as the CREDO trial, sick Kidney disease patients. We do know that this population is simply harder to treat. After all, they are generally much sicker individuals. But, no one has ever suggested withholding statins from everyone because of their failure in severe kidney disease. That of course would make no sense. Somehow though this is precisely what occurred after the negative Homocysteine trials appeared. And frankly it is even worse than that. These same trials often demonstrated a reduction in stroke rate with Homocysteine lowering. Yet, stroke reduction was ignored. For Homocysteine, the baby was thrown out with the bathwater. As a result, many physicians might be missing the opportunity to reduce a cardiovascular and cerebrovascular risk because of this jaded response to a handful of clinical trials. There are biases I suspect that went into the imbalanced condemnation of Homocysteine reduction.

The bottom line though is that we must try to be impartial when reviewing literature. And, we must try to be scientific. We need to acknowledge that medicine is a hybrid. It is a science practiced by diverse artists, the doctors. Each physician has his or her own palate and brushstroke. Although all doctors will use the same paints and canvas to create their image of medical management, the final drawings will vary greatly from one to the next. With this understanding we should all be a bit less critical of one another. To state with absolute conviction that one opinion is “right or wrong” should be reserved for the very rare event of certainty. And that is an event that is alarmingly uncommon.

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