Alternate medicine?

Orsino

Banned
Man is mortal. Things have always gone wrong with the human body and there have always been people who made a living trying to fix it.

The development of the scientific method brought with it a systematic approach to understanding disease and dysfunction, and the use of evidence in discerning best medical practice.

But outside of this core dynamic, many of the structures and traditions of health care seem to me arbitrary to some extent, and were medical history to be replayed I feel there are elements that could be quite radically different.

I'll give you some examples:

- Generalism amongst medical doctors: As far as I'm aware, in every country in the world trainee doctors are required to gain a broad knowledge and understanding of disease and dysfunction. However when doctors go on to specialise much of this knowledge will never be used again; a proctologist has very little need to understand neurobiology.

In an ATL might we see a divergence from the tradition of equipping all medical doctors to be generalists? Could the very concept of "doctor" have developed differently?

- The psychology/psychiatry distinction: Within OTL medicine there is a distinction between understanding the mind and understanding the body, and a further distinction between understanding normal mental functioning and understanding mental illness. As relatively young disciplines how might psychology and psychiatry have developed differently? In an ATL might they be considered one in the same?

- Occupational therapy and physiotherapy: These are two allied health professions with quite specific but in some ways also quite arbitrary remits. Occupational therapists address the patient's practical every day functioning and seek to improve health and well-being through activity. Physiotherapists typically address musculo-skeletal assessment and rehabilitation. In an ATL could these two roles be combined into one? Or both subsumed into the role of the doctor? Or never develop at all?

- Competition in medical research: A lot of time and money is wasted in medical research as different research teams race to find the answer to the same question and when one of these teams succeeds the work done by all the others becomes redundant. In an ATL might we see national governments or international organisations decide that some research is too important to be left to the free market and assign researchers to particular problems? Or even enforce co-operation in research?

So how about it, does anyone have any thoughts on these? I know medical history isn't everyone's interest but I'd love to hear any medical PODs of your own. Or maybe you have suggestions for alternate medical time lines I should check out?
 
I'd like to see a timeline where medicine is more humble and more fully embraces a trial and error approach. For example, if someone has a chest cold or early stages of pneumonia, hit it with one broad-spectrum antibiotic, and if that doesn't work, hit it with another. I used to think this was sloppy, but I've gradually come around and now think of this as good practice of medicine. For example, the microbe which causes Legionnaires' disease, that's a rare bird and must be awfully hard to diagnose, but can be treated with erythromycin with is a common antibiotic.

And for example, with depression, I have read that zoloft might work great for some people and hardly do a thing for others. Just that everyone's biochem is a little different, and perhaps surprisingly, sometimes another SSRI might work. Plus, that it's often important to phase down in steps even if the medication doesn't seem to be working, just that your body may have gotten used to it. (and I don't know how this pertains to changing from one medication to another, such as from one SSRI to another) In the book Hello to All That: A Memoir of War, Zoloft, and Peace, the author wasn't helped by prozac but he was helped by zoloft.
 
I'd like to see a timeline where medicine is more humble and more fully embraces a trial and error approach. For example, if someone has a chest cold or early stages of pneumonia, hit it with one broad-spectrum antibiotic, and if that doesn't work, hit it with another. I used to think this was sloppy, but I've gradually come around and now think of this as good practice of medicine. For example, the microbe which causes Legionnaires' disease, that's a rare bird and must be awfully hard to diagnose, but can be treated with erythromycin with is a common antibiotic.

As someone who works with this daily, I must react against this. Of course you treat suspected bacterial pneumonia (or other suspected infections) empirically before you get the species ientification and resistance profile back from the lab. But starting with broad-spectrum antibiotics is definitely not a good idea for community acquired pneumonia (unless the patient is bad enough to have at least severe sepsis in the SIRS scale) for several reasons. It drives resistance development unnecessarily, it wipes out the normal flora paving the way for C. difficile and other restistant opportunists, and it costs at lot more money per treatment.

What you should do (and in my experience most physicians do) is to start with an antibiotic (with as narrow spectrum as possible) suited for the most likely agent (both from a priori likelyhood and examination/patient history) and the regional resistance profile (so simple Penicillin V for pneumococcal pneumonia in my area).
 

PhilippeO

Banned
- Generalism amongst medical doctors: As far as I'm aware, in every country in the world trainee doctors are required to gain a broad knowledge and understanding of disease and dysfunction. However when doctors go on to specialise much of this knowledge will never be used again; a proctologist has very little need to understand neurobiology.

so a lot more Dentist style non-doctor ? Dentist seems unique that even ordinary people recognize it separation from other doctor. Why ? What gave Dentist enough advantage that people think its separate from other medical profession ?

i always annoyed that most people didn't generally care about Scientist, Engineering, Computer-guy, Government-man or Medical Doctor separation ? old ladies asking medical question to someone who have doctor, even he explain repeatedly that he specialise in some fields, movie showing scientist capable of biology, geography and physics without difference, people in the office annoy comp-guy regardless of problem in excel, cabling, internet, or virus without understanding that network guy might be different from someone who know calculation in Excel. Why Dentist managed to convince people that their fields is worthy enough to be paid attention ?
 

Orsino

Banned
so a lot more Dentist style non-doctor ? Dentist seems unique that even ordinary people recognize it separation from other doctor. Why ? What gave Dentist enough advantage that people think its separate from other medical profession ?

i always annoyed that most people didn't generally care about Scientist, Engineering, Computer-guy, Government-man or Medical Doctor separation ? old ladies asking medical question to someone who have doctor, even he explain repeatedly that he specialise in some fields, movie showing scientist capable of biology, geography and physics without difference, people in the office annoy comp-guy regardless of problem in excel, cabling, internet, or virus without understanding that network guy might be different from someone who know calculation in Excel. Why Dentist managed to convince people that their fields is worthy enough to be paid attention ?
That is a good question, dentistry is quite unique as a broadly recognised non-doctoral health profession and I think it probably has something to do with the fact that a dentist is one of the few health professionals most people will see very regularly.

Plus dental problems are common enough that it makes sense to have a dedicated professional, but they're also pretty unglamorous so I don't think doctors have any desire to subsume dentistry into their remit.

How likely is it that in an ATL you mightt see the role of the dentist expanded to include maxillo-facial work? Why not get the guy who pulls teeth to also wire the jaw?
 
so a lot more Dentist style non-doctor ? Dentist seems unique that even ordinary people recognize it separation from other doctor. Why ? What gave Dentist enough advantage that people think its separate from other medical profession ?

i always annoyed that most people didn't generally care about Scientist, Engineering, Computer-guy, Government-man or Medical Doctor separation ? old ladies asking medical question to someone who have doctor, even he explain repeatedly that he specialise in some fields, movie showing scientist capable of biology, geography and physics without difference, people in the office annoy comp-guy regardless of problem in excel, cabling, internet, or virus without understanding that network guy might be different from someone who know calculation in Excel. Why Dentist managed to convince people that their fields is worthy enough to be paid attention ?

Purely traditional. Dentists used to be non-academic (so were surgeons, but they were successfully subsumed into academic medicine). THis is all about path dependence, so a change in the academic structures of the early modern period is your best bet. That could get you a world where different medical fields are trained in different curricula, or even schools, from the start. But you'd need to break the dominance of university-educated physicians, because otherwise they will simply take control of any emerging field (as they did with surgery in the 19th and psychiatry in the 20th century).
 
That is a good question, dentistry is quite unique as a broadly recognised non-doctoral health profession and I think it probably has something to do with the fact that a dentist is one of the few health professionals most people will see very regularly.

Plus dental problems are common enough that it makes sense to have a dedicated professional, but they're also pretty unglamorous so I don't think doctors have any desire to subsume dentistry into their remit.

How likely is it that in an ATL you mightt see the role of the dentist expanded to include maxillo-facial work? Why not get the guy who pulls teeth to also wire the jaw?

Don't dentists who take the requisite specialisation already do maxillo-facial surgery?
 
One reason we have seen specialization increasing with time is that more and more can be done, and one person simply cannot know it all. Furthermore, in those specialties with surgery or other interventions it takes time to learn these skills, and one must use those skills on a regular basis to keep them sharp as well as keeping up with new advances. In general someone who does 5 procedures of type X a year is less adept than someone who does 20 or 50 and this becomes more important the more complex a procedure becomes.

To use an analogy, sure someone who has a private light plane license can, with coaching, land an airliner under ideal conditions and have a shot at not crashing. Is that a plane YOU want to be a passenger in? The other issue is, for an MD in the USA you need four years of college, four years of medical school, and three to eight years of postgraduate training before you are turned loose without supervision (depending on the specialty). If someone with less training is "just as good" then why waste the time, effort, and resources on the extra training?
 
As someone who works with this daily, I must react against this. Of course you treat suspected bacterial pneumonia (or other suspected infections) empirically before you get the species ientification and resistance profile back from the lab. But starting with broad-spectrum antibiotics is definitely not a good idea for community acquired pneumonia (unless the patient is bad enough to have at least severe sepsis in the SIRS scale) for several reasons. It drives resistance development unnecessarily, it wipes out the normal flora paving the way for C. difficile and other restistant opportunists, and it costs at lot more money per treatment.

What you should do (and in my experience most physicians do) is to start with an antibiotic (with as narrow spectrum as possible) suited for the most likely agent (both from a priori likelyhood and examination/patient history) and the regional resistance profile (so simple Penicillin V for pneumococcal pneumonia in my area).
Okay, so with suspected bacterial pneumonia, a doctor typically starts with a narrow-spectrum antibiotic. Using their best judgment of what's in the area, the patient's history and symptoms (travel, other people in family who have been sick, etc.), and perhaps other factors as well.

And I will agree whole-heartedly that the devil's in the details. We can talk about general principles of good medicine, and this is perhaps the kind of thing informed citizens should know about. But in the specific case of specific person being sick, it sure helps to have a medical professional right there.

And thank you for correcting my previous mistake and providing us with sound information.
 
Last edited:

Orsino

Banned
One reason we have seen specialization increasing with time is that more and more can be done, and one person simply cannot know it all. Furthermore, in those specialties with surgery or other interventions it takes time to learn these skills, and one must use those skills on a regular basis to keep them sharp as well as keeping up with new advances. In general someone who does 5 procedures of type X a year is less adept than someone who does 20 or 50 and this becomes more important the more complex a procedure becomes.

To use an analogy, sure someone who has a private light plane license can, with coaching, land an airliner under ideal conditions and have a shot at not crashing. Is that a plane YOU want to be a passenger in? The other issue is, for an MD in the USA you need four years of college, four years of medical school, and three to eight years of postgraduate training before you are turned loose without supervision (depending on the specialty). If someone with less training is "just as good" then why waste the time, effort, and resources on the extra training?
But why then continue the practice of general training? Why have medical students learn so much information that they will never use again when they inevitably specialise? Why not have separate and specific paths for neurology, dermatology, proctology, etc.

I'm not suggesting this would be a better system, I'm just asking if it is plausible that such a system could have developed in an ATL.
 
But why then continue the practice of general training? Why have medical students learn so much information that they will never use again when they inevitably specialise? Why not have separate and specific paths for neurology, dermatology, proctology, etc.

I'm not suggesting this would be a better system, I'm just asking if it is plausible that such a system could have developed in an ATL.

Well, as I said, it has its roots in a tradition of generalism that branched out under the weight of information that was added afterwards. If you change that, you can create a senario where medicine becomes a system, of separate specialisations (you already have dentistry and pharmacy as discrete curricula, it is certainly possible, but the reasons in either case are historical - the existence of pharmacist and dentist as non-academic professions - not practical)

As an aside, though, there is a case to be made for a thorough grounding across the discipline. If you don't have general theory, you'll struggle in general practice. I'm willing to concede we may be overdoing it, but bodies are interlocking systems, and you have to have a basic understanding of how they work overall to properly interpret symptoms. (Anecdote: my ex-gf had persistent pain in three molars. The dentist concluded they were infected from the root and needed to be pulled. After much soul-searching and scraping together the money for the implants, she told the story to her GP during a routine visit. It was found that her sinus was infected and the pain was radiating out. Two weeks of saline solution treatment, and no more issues. The dentist had either never heard of it or, more likely, forgotten.
 
(Anecdote: my ex-gf had persistent pain in three molars. The dentist concluded they were infected from the root and needed to be pulled. After much soul-searching and scraping together the money for the implants, she told the story to her GP during a routine visit. It was found that her sinus was infected and the pain was radiating out. Two weeks of saline solution treatment, and no more issues. The dentist had either never heard of it or, more likely, forgotten.

Additional examples of why a general knowledge is important are cases of psychiastrists noticing that what was initatialy thought to be anorexia nervosa was actually Crohn's disease (coupled with a personality disorder), and diagnosing cases of fever of uncertain origin (is it infectious? is it malignant? is it something autoimmune? autoinflammatory?). A case can definitely be made that the general training is unnecessary for some of the laboratory specialities, but not for physicians with direct patient contact. You run into things that are outside your immediate area of expertise most days, even if you are in a secondary or tertiary referral center.

What you could see is dentists being considered physicians, or combining pharmacists with the lab specialities (clinical microbiology, clinical immunology, cytology?). Possibly breaking off social medicine, environmental medicine etc into a separate cathegory with more emphasis on social sciences and statistics?
 
Last edited:
First off, most medical students are not really sure what they want to do until they have had some experience, so deciding on day 1 of training where you are going is not reasonable. Secondly, no specialty stands by itself. because the human body is a complex system, you need to have a good general understanding before you narrow down. Even as a specialist you find patients with a complaint of one sort have a cause based elsewhere.

In fact, in the UK for example, there was significant separation between surgeons and physicians, one was one or the other, up until relatively recently. These sorts of separations were found to be counterproductive and were done away with. In a way there is some "variation" as we still see flourishing "alternative" practices such as chiropractic, naturopathy, homeopathy, etc.
 
First off, most medical students are not really sure what they want to do until they have had some experience, so deciding on day 1 of training where you are going is not reasonable. Secondly, no specialty stands by itself. because the human body is a complex system, you need to have a good general understanding before you narrow down. Even as a specialist you find patients with a complaint of one sort have a cause based elsewhere.

In fact, in the UK for example, there was significant separation between surgeons and physicians, one was one or the other, up until relatively recently. These sorts of separations were found to be counterproductive and were done away with. In a way there is some "variation" as we still see flourishing "alternative" practices such as chiropractic, naturopathy, homeopathy, etc.

Chiropractors have gotten more academic in recent times, though.
 
I'll suggest an example of what was once a medical specialty that eventually was mostly subsumed into more general medicine (though it's now making something of a comeback): midwives.

Traditionally births were generally handled by midwives (who were also generally women). It's not until the 1900s that you have the general shift to hospital births and (usually male) surgeons in America (I can't speak for the rest of the world). The general argument was that midwives were uneducated women, unexposed to modern scientific knowledge, complete with campaigns implying that using midwives was dangerous and harmful to the mother and child.

One could imagine a society where this is different (either because midwives are seen as part of the greater scientific medical community earlier, or because male surgeons prefer not to bother with inherently female concerns like childbirth, perhaps due to cultural/religious taboos).
 
I'll suggest an example of what was once a medical specialty that eventually was mostly subsumed into more general medicine (though it's now making something of a comeback): midwives.

Traditionally births were generally handled by midwives (who were also generally women). It's not until the 1900s that you have the general shift to hospital births and (usually male) surgeons in America (I can't speak for the rest of the world). The general argument was that midwives were uneducated women, unexposed to modern scientific knowledge, complete with campaigns implying that using midwives was dangerous and harmful to the mother and child.

One could imagine a society where this is different (either because midwives are seen as part of the greater scientific medical community earlier, or because male surgeons prefer not to bother with inherently female concerns like childbirth, perhaps due to cultural/religious taboos).

In Sweden (where I live) the development was instead to regulate midwifery centrally, but then decentralize the actual practice (in the 18th century) with the goal of having one school-trained (then in special midwifery schools, now as an academic addition to a bachelor in nursing) midwife per parish (though that goal was achieved only in the late 19th century). The certified midwifes were then allowed to use forceps, and even perform symphysiotomy and fetotomy. Though there are and were obstetricians parallell to this, even now all uncomplication births (in hospitals) are handled by a midwife (up to and including needing forceps and ventouse, tocolytics etc).
 
Top