At the beginning of this year, National Medical Products Administration released the No.1 document in 2020-Guiding Principles of Real-world Evidence Supporting Drug R&D and Evaluation (Trial), which attracted great attention in the industry. Two years ago, the reporter of Economic Information Daily interviewed Fan Daiming, an academician of China Academy of Engineering. In the report "Academician Fan Daiming: Paying too much attention to the micro, medicine will go astray", Fan Daiming pushed for "real world research" and called for the reverse research of medicine.
Now, Fan Daiming is still busy, and the thinking about the development of medicine is also deepening: Why is the more modern medicine develops, the more intense it is questioned? What is the relationship between culture and medicine? How to reshape medical culture … Not long ago, Fan Daiming once again accepted an exclusive interview with the reporter of Economic Information Daily, and he solemnly proposed that culture should lead the development direction of modern medicine.
The picture shows Fan Daiming, academician of China Academy of Engineering.
Four major deviations in the development of modern medicine
Reporter: What do you think of the relationship between modern medicine and culture?
Fan Daiming: To answer this question, we must first realize the dilemma faced by modern medicine-modern medicine has greatly improved the average life span of human beings, but the question of medicine has never been so fierce as it is today.
As Roy Porter, a professor of medical history at Cambridge University, wrote: People have never lived so long and lived so healthily, and medicine has never achieved so much. However, paradoxically, medicine has never aroused people’s strong doubts and dissatisfaction as it is today.
In fact, there are four deviations in the development of modern medicine: first, medical research blindly develops to technology and penetrates to micro-level, which leads to over-differentiation of specialties, over-detailed planning of specialties and fragmentation of medical knowledge, that is, O2F1；; Second, modern medicine has become waiting medicine; Third, modern medicine has become antagonistic medicine; The fourth is medical alienation, which takes some natural processes of life and some natural changes of the body as diseases for excessive intervention.
Reporter: As for O2F1, you have elaborated it in detail when you were interviewed by us.
Fan Daiming: Yes. This situation is at least a problem caused by introducing simple research methods into medicine, that is, simply introducing science and technology into complex and variable human health care. Doctors are increasingly confined to narrow professional fields, and even can only see a certain disease, resulting in more and more drugs, but the curative effect is getting worse. I will focus on the last three biases.
Modern medicine has become waiting medicine. Modern medicine regards people’s health status as a linear process, from no illness to death due to illness. What is disease? It is to draw a line artificially according to some indicators, and when you cross this line, you are sick, and the doctor will treat you; If you don’t cross this line, the doctor won’t care.
Take stroke as an example. A person is a "good" person without a stroke, and a sudden stroke one day becomes a patient. After the onset of stroke, treatment can hardly play much role, but the money earned by patients in their lifetime is likely to be used up in the last few days.
Only at the end of the disease and the last few days of life, the curative effect is bound to be limited, and it will bring great pain to patients. This is waiting for medicine. If we work harder before we get sick, will the result be different? The "prevention of disease" advocated by Chinese medicine should give enough enlightenment to modern medicine.
Modern medicine has become antagonistic medicine. In the past, infectious diseases caused by foreign sources and a single cause were the greatest threat to human health, so it is understandable to "confront" all diseases as "enemies". However, at present, chronic diseases have become the biggest threat to human health, which is a problem in the internal balance adjustment of human body. If we still adopt the thinking of "confrontation", we are "confronting" ourselves, and we may not cure the "disease" but hurt other organs.
This "confrontational" thinking is also deeply influenced by culture. Modern medicine represented by western medicine originates from nomadic culture, and the survival rule of nomadic culture is "you die and I live"; In China’s traditional culture with thousands of years of farming society as the background, "harmony" and "you live and I live" are the mainstream. Therefore, treating cancer in traditional Chinese medicine is "treating cancer without seeing it" and how to better "survive with cancer".
There has been alienation in medicine. It is too serious to treat some natural processes of life and some natural changes of the body as diseases for excessive intervention.
For example, it is a natural process for a mother to give birth to a baby. If there are some problems during pregnancy, it is ok to check it occasionally, but now many pregnant women go for a B-ultrasound every month or two. You know, every medical examination is more or less harmful to people, but this kind of damage is within the tolerable range. But has anyone ever thought about how much long-term harm regular prenatal checkups will do to the fetus? What will be the consequences after many years? Actually, we don’t know.
Unbalanced medical culture
Reporter: What will the imbalance between medical development and culture, or the lack of culture in medical development, bring to medicine?
Fan Daiming: There are at least three consequences. First, with the help of science and technology, medical research on human body structure and even function has been advanced and thorough, reaching directly to genes, but medical knowledge of the nature of life is still far from being understood culturally, and this is the most important thing. You know, being sick is not only a physical illness, but also a life illness. The imbalance between medical development and cultural relations, or the lack of cultural medicine, makes modern medicine "out of her wits".
Second, worldwide, human culture (including medical culture) has been formed and developed for thousands of years (such as European culture, Indian culture and China culture), but now we are using a single-domain culture (such as medical ethics culture) with only a few hundred years to monopolize or even replace the global human culture for thousands of years, which seems to be somewhat "inadequate".
Third, compared with the past, the spectrum of contemporary human diseases has undergone fundamental changes, such as various endogenous senile diseases and chronic diseases, with multiple causes and multiple targets; In history, human life span has never been as long as it is now, and the biggest threat to health is often infectious diseases caused by external factors and single cause. Modern medicine is still using simple, linear and direct methods to deal with infectious diseases in vitro to deal with the complex, nonlinear, indirect and endogenous chronic diseases of human beings, so it often backfires.
From being out of her wits, to being unable to do what she wants, and then to being counterproductive, won’t this medical culture change its profession? We must make great efforts to reshape medical culture. Where medicine develops depends on what kind of medical culture to lead.
Reporter: Some people say that science and technology and humanities are the two wings of the progress of human society, and they are indispensable, otherwise they will deviate from the direction. It seems that the same is true for human health, medicine and culture.
Fan Daiming: Improper handling of the relationship between medicine and culture is not only bad for patients, but also harmful to doctors. At the memorial service, it is usually said that "the comrade died because of illness", but it is not said that "he died because of illness". In the event of an emergency, the seriously injured are sent to the hospital for rescue, and when notified, they will say "death due to injury", but they will not say "death due to injury". Also, "as long as there is one percent hope, we must use 100 percent efforts to rescue", which is right from the humanitarian point of view, but is it completely right in medical practice? This is a waste of money for some patients, a waste of effort for doctors, and a loss for society.
If "ineffective treatment", "ineffective rescue" and "medical pursuit of 100% success" have become "routine", isn’t it an excessive accusation and injury for doctors? This is also a cultural problem!
Cases of hurting doctors are endless, which is a more extreme phenomenon. Let those who hurt doctors be punished, even sentenced to death, so that the problem can be solved fundamentally and completely? No! We must think from the root of medicine, culture and values, so that we can embark on the right path.
"Four Persistences" Reshape Medical Culture
Reporter: In your opinion, what should be included in dealing with the relationship between medicine and culture?
Fan Daiming: First, we must adhere to the humanity of medicine.
Humanism is the highest realm of culture in the study of human nature, and its function is to ensure the safety, importance and dignity of life. There are two basic requirements of human nature: one is to pursue happiness, the other is to pursue immortality and hope to live forever. In fact, it is impossible for an organism to be immortal. People are the same, flowers bloom and flowers fall, the tide rises and falls, and everything is the same, which is inevitable in nature.
But the problem is that the single-domain medical ethics culture does not recognize that people will die, so they use technology to intervene in death. So there are three problems: first, the time of death has changed from unknown to known. Second, the place of death was moved from home to the ward. We used to take medicine home for illness, but now we send patients directly to the hospital to save their lives, even if we know there is little hope. Doctors in ICU and rescue room tried their best to rescue them, and family members outside tried their best to pay the money. It is likely that when the patient finally left, the family members failed to shake hands and say goodbye. The third is from natural death to technological death. An old expert in our hospital left when he was 92 years old. In the last two years, he became a vegetable, and his soul had already left this world. We still worked hard on his body and relied on a ventilator to maintain it. There are many such people, who have left this world although they are lying in hospital beds. They are covered with tubes but don’t know it. It can be said that they have no dignity at all. The doctor is looking at whether the pipe is impassable. All-pass is alive, no-pass is dead, and part-pass is part-live. Is that right? Isn’t this culture going to change professions?
In the past, both Chinese and western sacrificial customs fully considered the sanctity and dignity of life. At present, many hospitals offer hospice care, which fully considers the feelings of family members and the hospice care of medical staff for the dead. In fact, this is also a reshaping of medical culture.
Second, we must adhere to the integrity of the human body.
We should respect life and respect it. Life exists as a whole. With the infinite division, all the parts finally exist, but what is lost is life. Conversely, the sum of all parts is not equal to a whole, because the whole of medicine must have life. A whole with life is called a whole; There is no whole life, we call it a corpse.
The existence of life must depend on the whole existence. An elephant, we know at a glance, the blind can only rely on touch. When a blind man touches an elephant’s leg, he can tell that it is an elephant, but can he still recognize it if he touches cells or even molecules? If we go to the atomic and quantum level, everything is indistinguishable, can we still identify life forms? Therefore, medicine should not be too microscopic.
Einstein has long said that science pursues clarity, accuracy and purity at the expense of integrity. Similarly, the "accuracy" we blindly pursue in medicine is at the expense of life, which is also a culture and a culture with problems.
Third, we must persist in the complexity of life.
Life has great complexity, and the local and instantaneous research results can not explain the process and essence of life, nor can they be a panacea to save lives.
We know life now, which is too simple, but in fact it is extremely complicated. The existence of life, first of all, is the role of natural forces. Otherwise, how will life be spent in millions of years or even longer without medicine? This natural force is manifested in the ability of life itself to resist diseases and harm; Second, different organs can coordinate with each other and have self-consistency ability; Third, after a certain part of the body is damaged, it can compensate for growth and has the ability of self-repair; Fourth, metabolic ability, life and physical ability blend with the outside world, and absorption of order can discharge disorderly energy; Fifth, self-balance ability, such as water and electrolyte balance, white blood cell level balance, heat balance and so on; Sixth, the ability of self-protection, which is manifested in immunity, vomiting and excretion after eating bad things; Seventh, the reaction of spirit and consciousness to the above six abilities.
There is a saying that the "three magic weapons" for doctors to treat diseases are language, medicine and scalpel. Among them, drugs and scalpels are necessary, and the power of language is the greatest. There is a famous saying in the west, "To cure sometimes, to relief oft, To comfort always". This sentence means that for patients, soothing and comforting are the most important, and healing only accounts for a small part. In fact, even if the patient is cured, in the final analysis, it is the patient’s own internal natural forces that have played a role. The doctor just helped them outside, and never take advantage of it.
Therefore, medical intervention in life and health should first ensure that the natural forces of life play a role. If medical intervention exceeds or even replaces this ability, it is called overtreatment. From the development practice of modern medicine, there are fewer and fewer medical deficiencies, but more and more medical excesses.
Fourth, we should insist on the authenticity of the research.
At present, many medical researches are not true, but only one way to the end, from macro to micro, or from structure to small structure, from long time to short time. We must go back and return to the macro level, which is what we call reverse medical research. Only when the way back is clear and a circle is formed, it is called closed-loop research, and the correct results can be obtained. Historically, many great achievements in natural sciences, especially medicine, were obtained by reverse research.
The fundamental way to change the existing clinical thinking and improve the shortcomings of evidence-based medicine in medical research is reverse thinking. Reverse thinking involves many aspects, including real-world research. Real-world research may also have its own problems. If evidence-based medicine is combined with real-world research, especially reverse research on evidence-based medicine, we will be much more likely to get correct results.
Of course, four persistences are the necessary conditions for reshaping medical culture, and it is far from enough to be satisfied with these four aspects. I hope more people can join in and lay a more solid foundation for reshaping medical culture.
Learn from the sages 2,500 years ago.
Reporter: How to choose the starting point to reshape medical culture?
Fan Daiming: Some people say that to solve many global problems today, we should go back to ancient China 2,500 years ago and learn from the wisdom of Confucius. Confucius lived in the Spring and Autumn Period and the Warring States Period. At that time, there were "three religions and nine streams" and "hundred schools of thought". A large number of outstanding thinkers, represented by Confucius, looked forward to 2500 years and thought about 2500 years later, which set up an ideological monument for Chinese civilization and even world civilization that is beyond the reach of today.
So, where is the cultural essence of the Chinese nation for 5000 years? In my opinion, it is a people-oriented holistic view and an integrated view of the unity of man and nature. This is where the roots and ideological context of holistic integrated medicine come from. On the remolding of medical culture, the organic integration of holism of traditional Chinese medicine and reductionism of western medicine should be the only way.
In China’s traditional culture, everything in the world is divided into five elements: Yin and Yang, which are rooted in each other, and the five elements interact with each other. On this basis, Chinese medicine puts forward that essence is substance, which can be detected by modern medical means, such as hemoglobin, blood lipid, etc., but qi and spirit instruments can not be detected, but Chinese medicine doctors can perceive their state level by looking, hearing and asking. This is the common expression of structure and function, and it is the understanding of medicine by ancient Chinese medicine. Even in today’s advanced science and technology, Chinese medicine still shows strong vitality and good curative effect, even far beyond the cognitive level and curative effect of modern medicine in some aspects, which is worth learning and learning from modernmedicine with an open mind.
In the development history of traditional Chinese medicine, Taoism, Buddhism and Confucianism have contributed a lot, and the reconstruction of modern medical culture can gain important enlightenment from it. For example, Buddhists emphasize the cultivation of the mind, emphasizing a "clean" word and demanding that the mind be free from distractions. It is not easy to do this. There are always many distractions in my heart. Can I be healthy? If you want to calculate others every day, can you be healthy? Another example is that Taoists stress health preservation and emphasize a "quiet" word. Mentality is always manic, can you calm down and nourish your heart? Therefore, it is necessary to be calm in order to ensure health. For another example, Confucianism stresses governing the country, managing the world and helping the people, and emphasizes the word "respect", so as to respect nature, society and etiquette.
Science itself has no purpose, and good use can benefit mankind, such as nuclear power technology; If it is not used well, it can also be used to kill people, such as nuclear weapons. Whether it is used well or not needs the guidance of culture. The same is true for medicine. The profound traditional culture of China, whose holism and integration view are integrated with the reductionism of western medicine, will form a new medical culture. Only by forming an integrated health service system, including an integrated medical education system, a medical research system, a medical service system, a medical prevention system and a medical management system, can we lead the new direction of medical development and go faster and further in implementing the healthy China strategy and caring for human health.
[Editor’s Note] This is an interview with Academician Fan for four consecutive years —— Fan Daiming, an academician of western medicine in 2017, why I support Chinese medicine in 2018, Academician Fan Daiming: paying too much attention to the micro, and medicine may go astray in 2019. Visiting Academician Fan Daiming three times: modern medicine needs reverse research, and this article will be published in 2020 with the theme ". Academician Fan has thought a lot about the integrated health service system to be built in the future. During the anti-epidemic period, he wrote a 50,000-word masterpiece "On the Correct Practice of Medicine", which was published in Medical Contention in four phases. The interview next year (the fifth year) may focus on this theme. (Reporter Wang Xiaobo reports from Qi Wang)
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