The explosion in health care options now available to the average North American can be daunting. But with a framework for what constitutes good medicine, bad medicine and everything in between, you should be able to dispel some of this uncertainty.
To get a complete picture of both good and bad medicine, one has to look at that medicine in three dimensions.
The first dimension is the quality of the therapy itself. This dimension is a number line. You could think of quality scores existing on a scale from minus-10 to plus-10.
The second dimension is the approach of the clinician and how well they can deal with disease in two key regards: a holistic approach to deal with the whole body, and a reductionist approach, which focuses in on one part in isolation. This dimension can be thought of as a spectrum from holistic to reductionist and how well the clinician can cover that entire spectrum.
The third dimension is the goal of the patient, and is a spectrum that goes from illness to wellness.
The Quality of Therapy
This dimension represents the therapy itself—the medication, herb, supplement, medical device, surgery, procedure, etc.
If a form of medicine scores poorly here, it is very hard to make up for that with a better score in the other two dimensions we will use to evaluate it.
To evaluate the quality of a therapy, we need to look at four objective criteria that represent the spectrum between good and bad medicine.
The four objective criteria for therapy quality are:
- Safety. Primum non nocere or ‘First, do no harm.’ This point is by far the most important; risky therapies should only be performed in the gravest of circumstances—such as life-threatening or disabling illness.
- Effectiveness. How well does the treatment or therapy perform? This can be a straight-forward answer for most single therapies. For whole medical approaches (such as functional medicine, conventional medicine, traditional Chinese medicine, etc.) it can be challenging to answer this question without taking into account the second and third dimensions we’ll discuss shortly.
- Practicality. How practical is the treatment or therapy? A very safe, effective, evidence-based therapy is not good medicine if it costs $100,000 per treatment or you have to travel halfway around the world every month to receive it.
- Evidence. What level of evidence supports the therapy? The levels of evidence can range from experimental (no evidence—but may be a good idea) to clinician experience and case reports (some evidence—but may not have been validated by other clinicians or scientists) to various levels of scientific studies of which the gold standard of evidence is the double-blind randomized controlled trial.
The Clinician’s Approach
A doctor’s approach to the practice of medicine resides within a continuum between a holistic and reductionist view of disease.
In a reductionist view of medicine, the body’s systems are treated in isolation. So, if you have a disease, the best course of treatment is usually to target the symptoms of that disease if the root cause is not apparent and immediately treatable.
This approach works particularly well in situations where acute care is needed to provide urgent treatment, like fixing a wound, or saving a patient from immediate death due to disease.
Holistic approaches work by treating disease within the context of the body as a whole, and usually the person’s lifestyle as well. These approaches are particularly good for the chronic conditions that currently top the charts as cause of death, like heart disease. For example, they often aim to address nutritional deficiencies or lifestyle habits that are the root cause of disease.
The contest between a holistic approach and a reductionist approach has been called by some as the art of medicine versus the science of medicine, but I find that terminology misleading. It implies holistic practitioners are unscientific and reductionist (or conventional Western) practitioners are not creative or imaginative.
The art and science of medicine encompass science, creativity, holism, and reductionism—they all play important roles when the need arises.
The ideal clinician can cover the full spectrum from holistic to reductionistic treatment. Good medicine should encompass both views of disease, as the most profound answers arise from the synthesis of the two.
The style, philosophy, and experience of the individual practitioner are the greatest determining factors in how much of this spectrum is delivered to the patient, but the underlying medical approach that individual practitioners follow will have great influence as well.
The Patient’s Goal
While the first dimension reflects primarily the therapy and the second dimension reflects the individual practitioner, this dimension represents patient’s expectation and the medical tradition or system of medicine best suited to meet that goal.
Many medical traditions strive only for average health are neither good nor bad medicine—they are only as good as they get their patients: average.
Their primary goal is to pull the patient away from illness to average health but not necessarily go beyond this. An ideal approach would be to not only elevate the patient from the depths of disease, but to deliver them to the highest reaches of optimal wellness.
Good medicine, and by extension the best medicine, should deliver high marks on the quality of therapy, have a practitioner who looks at the patient holistically while reducing necessary components when needed, and always be striving for the optimal health of their patient.
Armen Nikogosian, MD, practices functional and integrative medicine at Southwest Functional Medicine in Henderson, Nev. He is board-certified in internal medicine and a member of the Institute for Functional Medicine and the Medical Academy of Pediatric Special Needs. His practice focuses on the treatment of complex medical conditions with a special emphasis on autism spectrum disorder in children as well as chronic gut issues and autoimmune conditions in adults.