Medicine for the millennium: the challenge of postmodernism

Jonathan J Chan and Julienne E Chan

MJA 2000; 172: 332-334

Abstract 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 engaged.

Thomas Docherty1

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 impartial observation.3 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 knowledge.

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 aesthetic practice;5 a sensibility;6 a consciousness, the cultural logic of late capitalism and the crystallisation of previously independent developments;2 a number of related tendencies, values, procedures and attitudes;7 and the general condition of contemporary Western civilisation.8

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 present.10

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" resounded12 as humankind grabbed the keys and set about unlocking the doors, discovering what lay behind them, and determining the boundaries of knowledge.

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 and arthritis14 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 experimentation.

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.

Evidence-based medicine is modernist medicine
He's the best physician that knows the worthlessness of most medicines.

Benjamin Franklin15

Much 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 medicine.

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 journals.

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 all".19 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 modernist ideals
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.

Alexander Herzen20

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 symptoms.

The future
There is an ominous cloud in the distance though at present it be no bigger than a man's hand.

Arthur Stanley Eddington22

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.

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 today.

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, WA.
Jonathan J Chan, MB BS, Dermatology Registrar.

University of Western Australia, Nedlands, WA.
Julienne E Chan, BA(Hons), PGDipEd, Postgraduate Scholar.

Reprints will not be available from the authors.
Correspondence: Dr J J Chan, Department of Medicine, University of Western Australia, 4th Floor G Block, QEII Medical Centre, Verdun Street, Nedlands, WA 6009.

©MJA 2000
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