Practicing Reductionism
I had the pleasure of attending courses at the Illinois College of Optometry. The first speaker was the well respected “glaucoma guru” Michael Chaglasian, O.D., FAAO. I learned a lot about the latest in glaucoma, including summaries of studies and the practical application of this information. Optometrists and ophthalmologists understand that glaucoma is more than high eye pressure. A very important aspect of practicing eye care is recognition of the disease. The diagnosis of glaucoma can be difficult to make. The decision to treat or not to treat a patient can also be difficult. The doctor has to look at all of the data, including what he or she sees and put all of these parts into a whole. A clinician must factor in various test results as well as use experience and personal judgment. This wasn't my first glaucoma lecture, and as I review my notes I noticed a trend. A significant portion of the lecture involved analysis of data sets. The disease itself could possibly be reduced to numbers. Most good doctors will say this is not the case, even a good lecturer will emphasize we must go beyond the number, look at the whole, not just the pieces. It is often difficult to get there when the entire presentation prior was about...the numbers.
I see this trend not just in eye care, but in all other areas of medicine as well, almost any physician you see will calculate various risks based on a numeric system: blood Pressure, BMI, LDL, HDL, ANC, AN1, ANA, CBC, TSH the list goes on and on. Have you ever wondered why this is? This of course is how "we" (scientists? Physicians? Human beings?) most often try to look at all natural phenomenon. We assign pieces to the part. We break kingdom into phylum, class into orders, order into species. We break matter into particles, particles into elements, elements into atoms, atoms into subatomic particles. The common analysis of anything natural is to reduce it. I wouldn't say that this is inherently bad. Explaining the human body this way was just a natural extension. In health care for example, overall life expectancy in developed countries is longer than it ever has been. But isn't it important to feel like a person as a whole when you leave a doctor's office, not just a series of tests and numbers? Shouldn't treatments and recommendations consider the entire body, the entire system? Is it even possible to do this?
Science is reductive. This helps with the explanation of concepts and natural phenomenon. If we are to understand reductive healthcare, I think it is important to understand how the idea of reducing "things" to parts began. I certainly don't have a degree in history or philosophy but I know a story or two. Most of us might recognize the name Pythagoras. His theorem is often taught in geometry. Pythagoras is known for starting a group, or as some would say, a cult, of followers known as Pythagoreans. They were dedicated to figuring out the secret harmonies and proportions of anything and everything in nature. Pythagoras was obsessed with sound. One of the many legends associated with Pythagoras is that of the five hammers. The story is that one day on a walk he heard a beautiful sound as he passed by a building. Pythagoras decided to investigate. Inside the building he saw five blacksmiths hammering away. They created this strange combination of sound that he had not heard before. It was something he felt was a "new" sound that did not at all sound like a single hammer. At first he thought the sound had to do with the force with which each man was hammering. So he made them exchange their hammers. But the sound persisted. Then he concluded that the sound, the harmony, that he heard was not in the men or their muscles but in the instruments. The instruments each had very specific weights. He measured the weights of the instruments and discovered that four of the five were in a marvelous set of proportions. One measured 12, one measured 9, one measured 8, and one measured 6 (3/4, 2/3 and 1/2). The story continues that he went home and began a series of calculations. These calculations led to the first sketch of harmony, as we know it. This was the first time the idea that numbers can reason sound appears.
Perhaps this system of breaking down natural phenomena has been around longer that Pythagoras, but he and his followers created an entire lifestyle around this concept. German philosopher Immanuel Kant said that the real founder of philosophy was Pythagoras. Kant placed great deal of importance on something that clearly mattered to the Pythagorians: the harmony of nature. In his book The Critique of Judgment he attempts to account for the nature of the universe, by ascribing an order of all things. Kant wrote that science demands that we be able to think of nature as a totality of parts. That is we must begin classifying species and genera and ordering various phenomena we find in nature.
It is easy to see how – and why – we got here. Reductionism has helped with the development of antibiotics, the concept of management of hypertension and even erectile dysfunction. But have we reached our limit? Is it time for the pendulum to swing slightly toward a holistic approach?
It is also easy to see how the current paradigm may be hurting us when we look at certain elements. The current paradigm involving prevention of heart attacks and strokes and their relationship to cholesterol seems to lack a global perspective. The current conventional wisdom is that high cholesterol is a disease, that if your LDL is high or your overall cholesterol is high you must lower it. But high cholesterol is just one risk factor. Cholesterol medication is intended to lower ONE risk factor. High cholesterol predicts a higher chance of heart attack or stroke than normal cholesterol. You can reduce your probability of a heart attack by swallowing a statin, but if we were to treat several hundred people that way, only one heart attack would be prevented. That one heart attack is only in a society of males. Statins have demonstrated little to no reduction in the prevention of strokes and heart attacks in females. Yet these medicines are prescribed in very high volumes. Why? Because they help reduce cholesterol, which is a number not a disease.
If we are to consider a pendulum shift we must at least begin to criticize reductionism, even if this is just for an exercise in logic. Are we taking for granted that the various things are just parts of a whole? Is the human body just a bunch of molecules or is there something or things that we just are not able to measure, see or understand yet? When we treat with a reductive mentality we are assuming that we have all of the elements involved with the whole. Kant discovered this himself: perceptions are limited, and therefore appreciation of the pieces does not give us the appreciation of the whole. For example can we really conceptualize infinity? Kant suggests that if you’re dealing with numbers in mathematics and science you can always go from one magnitude in one size to another, and always keep going. You can start counting and continue infinitely. Kant suggests, however, when you begin perceiving things that are progressively larger, there is a certain point at which you reach a limit. You simply can't mentally comprehend a number beyond a certain limit.
How does this contemplation of infinity apply in the real world? For those of us who have seen the Sistine Chapel this may resonate. You can perceive pieces but it is very difficult if not impossible to perceive and conceptualize the whole when you only look at parts. You try to take the whole thing in and you can't. You can comprehend multiple but you cannot comprehend them all in a single instant this way. The beauty of the Sistine Chapel lies in the beauty of the whole. However our reason demands that we comprehend it as pieces to a whole equally as to a whole itself. We just can't.
Have we failed to conceptualize the big picture in health because we break it down into parts? Is antibiotic resistance an example of the limitations of this reduced view? Perhaps the rapidly increasing obesity epidemic, or pesticides that no longer work are part of failure to conceptualize. An exercise programs that cause us to plateau, or glaucoma that doesn't respond to treatment could be signs as well.
I would not mandate that we stop using antibiotics, or that we stop the diagnosis of hyperlipedemia. I also still want to know the nutritional data of the food I eat. I do however ask that both doctors and patients try to incorporate the "whole" concept. For example when blood pressure rises during a routine physical, why not mandate or prescribe 30 personal training sessions or physical therapist treatments for those at higher risk to be done within 60 days instead of 60 pills to be swallowed in 30 days?
One reason may be that insurance doesn’t cover it. Insurance isn’t interested in preventive care, or they would consider exercise and nutrition preventive. Hasn’t the automotive insurance industry taken this approach? Better, safer drivers and still make a profit? Perhaps the insurance debate is best suited for a different post, but I would hope “they” are the reason we can’t demand healthcare take a more holistic approach.
Mindset also matters. Often people with holistic views are easily criticized, mocked and berated for their views. The cynic is quick to judge when herbs, vitamins and pills are pedaled for profits, but that is not holism in medicine. Holism in medicine would include keeping an open mind instead of being hypercritical of those who consider healthy food more than just the correct amount of vitamins and minerals. Holistic medicine would include demanding that your doctor looks you in the eye and treats you like a person instead of intermittently looking up toward you as notes are typed into your chart. Holistic medicine would include real prescriptions and treatments beyond pills and drugs.
Most optometrists who practice "behavioral optometry" understand these concepts. We often look at vision as a whole rather than the 20/20 eyesight that is of little necessity to most children. We think in terms of the body's influence on vision and the visual influence on body movement. When analyzing a case how the patient responds becomes more valuable than any number collected.
When I treat my glaucoma patients, I have a top-down approach. Patient -->disease--> results. Visual function and its impact on life is just as important. These things are certainly taught at lectures I attend, but sometimes there is failure to emphasize. As a self-declared eye nerd, it is hard for me to be overly critical of reducing the body to parts. I am one who enjoys learning the latest in glaucoma treatment. I thank those who try to impart wisdom to their peers including Dr. Chaglasian, but I hope all of us in healthcare and all of us who receive healthcare consider more than any number when dealing with a person.
