" The fact that medical treatment is not invariably followed by clinical improvement is not one that those interested in medical quality- be they patients or doctors- can ignore." says Dr. William G. Pickering, in his article in the recent Lancet entitled " Does medical treatment mean patient benefit?" He goes on to add that " among the diverse selection of problems presenting to the medical oracle, a proportion- appendicitis, fractured limbs, and pneumonia- are unmistakably curable; and success in anesthetics, fertility regulation, and sundry other specialties add weight to the inaccurate but extant notion of limitless medial power." ( emphasis mine ). There are three kinds of human problems; treatable diseases which are in the minority,diseases and human problems for which medical treatment may or may not help, and the third, untreatable diseases. Anecdotal evidence abounds in showing us that we are fallible, but in the statistical scientific world anecdotes have no place. In reality they do tell us the sad tale. There is no incentive to report the uselessness of medical interventions, although they occur regularly. Even in the eyes of the law if enough doctors practice a particular remedy, then it becomes right. ( Bolam Vs Friern Barnet Hospital Case 1957).

Clinical medicine abounds in uncertainty at all levels. So far the effort has been to sweep it under the carpet and never face the reality in medical practice. The trend is changing and there is an awareness now that clinical decision making is very complex and complicated involving both rational scientific thinking and in equal measure intuitive thinking. In fact, Dr. Katz goes one step further when he says that the doctor’s defense against ignorance and uncertainty are a greater difficulty in doctor-patient relationships than the patient’s ignorance.

In contrast to the usual industrial way of working, medical practice has always been beset with imprecision and imponderables, in terms of diagnosis, treatment and the outcomes of the former. These tend to increase in relation to individual patient care. In the present set up it has become much more than in the past, what with medico- legal, ethical, and sociopolitical changes having entered the arena. Clinical medicine confronts the clinician with his ignorance daily, which is due to the deficiencies in medical knowledge as a whole. The imprecision and uncertainty will increase inversely proportionate to the pressure on the time of the physician, making him spend less and less time with the patient. There is a need to educate the new entrants to the profession about the role of uncertainty in medical practice, as otherwise they will get overwhelmed by it when it confronts them head on.

Another area which makes medical practice imprecise is the impossibility to predict the future in the human system with the present scientific methods. I have written about this many a time in the past.The science of probabilities started with philosopher Pascal in the 17th century, we did not use it in medical science because of the influence of Descartes. We have now realized our folly. To give one small example let us take the exercise stress ECG test being done on asymptomatic apparently healthy population to predict the future outcomes. The results are presented to the patient as positive or negative. Both the above may be wrong because of the large number of false positives and false negatives which are the rule in this situation. Life becomes miserable for most of them as either they get reassured for wrong reasons or are are lulled into inaction where the vulcano could erupt any time. Sense seems to have prevailed on the thinkers and Drs. Gray Diamond and JS Forrester have devised a probability scale to aid the diagnosis of coronary artery disease, in place of the present positive-negative paradigm, which is meaningless.

Clinicians must realize that their uncertainty is at the root of many unnecessary technologies used in diagnosis. Diagnosis is subjective and needs, in addition to all the textbook rules, the experience of the clinician. It is now accepted that clinicians should develop better communication skills and be able to share their ignorance and doubts with the patients honestly. This is the best method to make the patient also a partner in the decision making process rather than keeping him in the dark and getting into trouble later because of medicolegal problems. Paternalism in medicine should give place to partnerships between patients and doctors. Afterall ignorance is universal and both the doctor and the patient could have their legitimate ignorance although both have their expertise in different areas. There is one exception to this and that is in dealing with patients who have emotional and anxiety states as their main problem. The doctor should be able to understand that during the initial interview and be able to diagnose the problem then and there. The latter situation warrants the greatest care to see that their anxiety is not enhanced by the doctor expressing his doubts to the patient.

With the present day knowledge explosion there will be more confusion in the field of medical practice like in any other field and doctors will have to be on their guard. Simplistic market forces are not likely to work in the medical field and society may demand much more from the medical profession in times to come in response to new knowledge in all fields of human endeavour. We must enter into a new understanding with society and then face the challenge squarely, putting all our cards on the table and not keeping any close to our chest. Honesty is the best policy even here. Law of probabilities is our better bet than the reductionist science paradigm. Chaos, a new science, is making headway in all fields including physics, and we in medicine should wake up to understand that human dynamic organism obeys only the holistic chaotic rule, rather than the organ based specialties.

All aspects of the outcomes of our interventions also should be made known to the patients. Recent meta analysis of Coronary bypass surgery after twelve years showed that in terms of increasing longevity, the operation did not benefit 84%, but in terms of relief of pain and severe disability it did help a lot. When this is made known an asymptomatic patient will opt out of the offer, without any risk for the clinician. One more reason why we should be open in our attitude. To do that with confidence we should keep in touch with new knowledge pouring in at a phenomenal rate daily. The knowledge changes so fast in medical field that one should be a life long student. Change is science and dogma is ignorance and unscientific.

" Clinicians can not afford to avoid uncertainty or pass it off as inherent aspect of the art of medicine. Certainty is a delusion-only uncertainty is certain......this must be acknowledged and addressed explicitly, especially in clinical training, if reason is to be used most effectively to improve the quality and cost effectiveness of clinical practice." say Drs.Logan and Scott, from Auckland in NewZealand. To come back to my friend who thinks that medical science has done wonders, I may have to admit that we have been able to conquer only one disease so far, that is small pox- it was done with the old granny’s wisdom of the vaccine, and not by any hi-tech stuff that we talk about. Before believing that spare part surgery and the like are a panacea for human ills, one must have some measure of understanding of the type and cost of life for the unfortunate patient following these procedures. Medicine has been doing and will continue to do, the same old dictum of Hippocrates " to cure rarely, comfort mostly but to console always."