the millennium: the challenge of postmodernism
Jonathan J Chan and
Julienne E Chan
MJA 2000; 172: 332-334
||As the new millennium dawns, Australian society is becoming more
postmodern, whereas the medical system remains increasingly
modernist in its outlook. In this article, we discuss the emerging
prevalence of postmodernism and examine current medical education
and practice strategies, such as evidence-based medicine, from a
postmodern perspective. We argue that if medicine does not respond
to the ideas of postmodernism, which challenges the concepts of
truth and our ability to be objective, it may become increasingly
irrelevant to the needs of a changing society.
Examining the state of medicine in a
postmodern world is important to a profession increasingly reliant
on science and technology within a society increasingly distrustful
of such a modernist approach. Does medicine run the risk of becoming
outmoded in the face of the postmodern expectations of its patients?
This amorphous thing [postmodernism]
remains ghostly -- and for some, ghastly -- for the simple reason
that the debate around the postmodern has never properly been
Asking the question "what is postmodernism?" is a
(post)modern-day equivalent of trying to capture Proteus, "for the
concept is not merely contested, it is also internally conflicted
and contradictory . . . Postmodernism is not something we can settle
once and for all and then use with a clear conscience".2
The term "postmodernism" itself inevitably leads us back to
modernism -- whether it be to replace it, reject it, re-evaluate it
or revitalise it.
Modernism can, in short, be characterised by belief in the
existence of truth, objectivity, determinacy, causality and
It has been described as "a search for an underlying and unifying
truth and certainty, a search for a definitive discourse that makes
the world and self coherent, meaningful and masterable".4
Modernism thus seeks to capture, define, understand and control
To return to postmodernism, definitions abound. It has been
variously described as an epoch or historical period;1
a theoretical and representational mood, a cultural epoch and an
a consciousness, the cultural logic of late capitalism and the
crystallisation of previously independent developments;2
a number of related tendencies, values, procedures and
and the general condition of contemporary Western
These definitions are equally valid, inclusive, exclusive,
overlapping, complementary and contradictory. For example, in
contrast to descriptions of postmodernism as a historical period, or
a consciousness, Bauman argues that the notion of historical
succession is an illusion, and that the postmodern era is a
philosophical and sociological re-evaluation of modernity.9
Jameson goes further, to suggest the disappearance of a sense of
history in favour of perpetual change in a perpetual
While these definitions encompass the historical, the aesthetic,
the philosophical, the sociocultural, and the politico-economic,
Lyotard has described postmodernism as "also, or first of all, a
question of expressions of thought".11
From this perspective, one view of postmodernism is that it is the
third stage in the evolution of Western conceptions of knowledge,
society and culture. The premodern, or classical, era was based on
the spiritual and the mythological, and can be summarised by
Anselm's credo "I believe so that I might understand".12
The gods (and later God), not humanity, were the centre of the
universe. The modern age of the Enlightenment saw a radical change
in perspective as humanity, empowered by science and reason, took
centre stage. Descartes' axiom "I think, therefore I am"
as humankind grabbed the keys and set about unlocking the doors,
discovering what lay behind them, and determining the boundaries of
As humanity's glorious hopes for self-determined science,
progress and freedom waned, disappointment and disillusion set in.
At the turn of the century, the prospect of the new age of
technology heralded hopes for a better world, free of disease and
social inequality. Yet, at the dawning of a new millennium, the fact
that these promises have not been fulfilled has led to increasing
doubt about the ability of science to heal and liberate. Although
science has generally improved human health and comfort, scientific
advances, such as the prolongation of human life, have resulted in a
plethora of other problems which medicine and science have
difficulty addressing. The widespread use of unconventional
therapies in chronic illnesses such as cancer13
shows that patients are seeking treatment which conventional
scientific medicine cannot provide.
Bauman has suggested that Wittgenstein's description of
understanding as "knowing how to go on"9
encapsulates this current era. The evolution from believing to
knowing the facts leaves us at a point of knowing from experience,
with the credo "I experience, therefore I try to make sense". In
line with a move away from the overarching themes and theories of
the Enlightenment, Lyotard has suggested that postmodernism can be
simplified to a disbelief in métarécits, or philosophical
metanarratives, such as "Science"and "Truth", in favour of the
petit récit, the small narrative based on lived lives, the
diverse, the complex and the unique.8
Such an approach acknowledges individuality, complexity and the
subjectivity of personal experience. The postmodernist paradigm
cannot accept that all things may be understood and mastered through
science. The validity of intuition and experience is considered
equal to that of traditional methods of observation, induction and
If society believes that the rational, objective truths and
certainties of science and medicine are not as true and not as
certain as they once may have seemed, where does that leave a
practice of medicine which continues to base itself on a modernist
approach? Medicine is resolutely progressing down a path of innate
modernity. We discuss two aspects of this trend: evidence-based
medicine and clinical pathways.
medicine is modernist medicine
He's the best physician that knows
the worthlessness of most medicines.
has already been written about the benefits and caveats of
evidence-based medicine (EBM). EBM considers patient management
based on available data and medical literature as conceptually vital
and important for best care. Since its inception in the early 1990s,
EBM has had widespread impact on the teaching and practice of
A postmodernist would regard EBM and the value it places on what
is considered to be "current knowledge" as a modernist concept. A
postmodernist would question whether current science and technology
have the ability to give us the "evidence" vital to the practice of
EBM. Thus, EBM is very likely flawed given that "the evidence is
based only on our current value systems, which can dramatically
alter with new advances in our understanding of nature".16
Proponents of EBM would argue that the constant search for current
data would ensure that the practice of medicine is kept abreast of
whatever new trends may occur. However, another disturbing
consequence of EBM is not only the quest for the right sort of data,
but also the essence of the data itself. EBM journals are edited by
combinations of physicians, epidemiologists and other experts, who
determine the importance of the research. Currently, 98% of articles
reviewed are rejected.17
Already, there is a worrying trend that only well-funded, large,
multicentre trials are published in first-rank, high-impact-factor
Many recent advances in clinical care have been determined from
pharmaceutical trials. How do paradigm shifts occur when the
motivation for research is biased, not towards "best evidence", but
rather to that which would guarantee high-profile publication or
sufficient pharmaceutical sales? The recent furore over a
high-profile researcher who was not allowed to publish her findings
because they contradicted claims about the therapeutic efficacy of
the products of her pharmaceutical funding body is an example of how
research is increasingly driven by profit.18
In addition, examination of medical literature shows a paucity of
articles which report negative findings or use qualitative research
methods. Surely the determination of "best evidence" requires
consideration of such data? The question is therefore, not
"what is 'best evidence'", but "how is 'best evidence'
determined" and "is it really the 'best' evidence"?
Most physicians would argue that the practice of medicine is an
art -- an ill-defined combination of experience and judicious use of
knowledge. EBM teaching emphasises "knowledge" -- learning the
"facts" and knowing the "literature". Sackett et al recognised this
in their own exhortations that EBM is not "cookbook medicine", and
that the "external clinical evidence can inform but not replace
individual clinical expertise and it is this expertise that decides
whether the external evidence applies to the individual patient at
However, in teaching EBM to medical students, there is a danger of
"dumbing-down" medicine to the lowest common denominator of
understanding facts and applying treatment algorithms without
applying Sackett's caveats. The emphasis placed on acquiring medical
knowledge may produce practitioners who have no understanding of the
uniqueness of each patient.
Clinical pathways and diagnosis-related groups are
I am truly horrified by the modern
man. Such absence of feeling, such narrowness of outlook, such
lack of passion and information, such feebleness of thought.
One of the major arguments against modernism and its advances is
the dehumanisation of society. From a postmodernist view, the
individual is now a faceless number in the databank of society.
Technological advancement and efficiency "ha[ve] left people feeling
disconnected with one another".12
Campion, in an editorial on "Unconventional medicine",21
posits that, "though Americans want all that modern medicine can
deliver, they also fear it. They may resent the way that visits to
physicians quickly lead to pills, tests, and technology . . . [they]
also may seek out unconventional healers because they think their
problems will be taken more seriously".
In an effort to rationalise the growing health budget, Australian
health providers are now determining costs through funding by
classification of diseases through diagnosis-related groups (DRGs)
and clinical pathways. The benefits are obvious: greater efficiency
in treatment has meant reduction of hospital waiting lists, reduced
hospital stays and reduction of costs. The downside is the
dehumanisation feared by the postmodernist. Proponents of the system
argue that the benefits of more people being treated outweigh the
apparent loss of identity. Yet, the outcome of this method of
medicine is far more sinister than it seems. The loss of identity
and the classification of admissions as DRGs have resulted in a
health system which encourages medical practitioners to focus only
on disease and to fail to understand the individuality and
uniqueness of each patient. The fact is that DRGs and clinical
pathways are preparing a future generation of medical practitioners
who will be very specialised in treating patients according to such
pathways, but little prepared for significant deviations from them.
Clinicians are becoming very adept at procedures and skills
determined by diseases and not by the individual patient's signs and
There is an ominous cloud in the
distance though at present it be no bigger than a man's
Medicine is continually
changing. It came into existence with the Enlightenment and gained
scientific maturity in the modernist age. Yet, the current
foundation of medical knowledge (EBM) and its essence of practice
(DRGs, clinical pathways) are significant constraints which will
inhibit its ability to change with the times. In effect, medicine is
becoming a modernist phenomenon which can neither progress nor
provide the necessary service to a society which is increasingly
postmodernist. In the past, there were fewer alternatives to medical
practice. Nowadays, the needs of society are met by allied health
professionals, naturopaths and other, similar therapists.
Arthur Stanley Eddington22
The role of the medical practitioner is already changing. Doctors
are now "healthcare providers" who administer "health services".
Patients are now "clients". It is likely that the medicine we know
will become just one part of a holistic health service which
includes other practitioners currently regarded as "alternative".
Producing medical practitioners who know only clinical pathways and
DRGs further widens the gap between the modernist model of
dehumanised science (the grand narrative) and the postmodernist
model of unique, lived experience (the small narrative). Unless the
practice of medicine becomes more focused on the unique individual,
with understanding of the limitations of the modern science of
medicine, our role runs the risk of becoming less relevant to people
||Jonathan Chan was supported by the Janssen-Cilag Dermatology
Research Fellowship of the Australasian College of Dermatologists
and the Amy and Athelstan Saw Postgraduate Research Fellowship of
the University of Western Australia. Julienne Chan was supported by
an Australian Postgraduate Research Award.
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|Authors' details |
||Royal Perth Hospital, Wellington Street, Perth,
Jonathan J Chan, MB BS,
University of Western Australia, Nedlands,
WA. Reprints will not be available from the
Julienne E Chan, BA(Hons),
PGDipEd, Postgraduate Scholar.
Correspondence: Dr J J Chan, Department of Medicine,
University of Western Australia, 4th Floor G Block, QEII Medical
Centre, Verdun Street, Nedlands, WA 6009.
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