Does the Medical Expert Really Know Best?

Editors Note

This article was co-authored by Stephen C Schimpff, MD and Harry A Oken, MD. Stephen C Schimpff, MD, MACP, is a quasi-retired internist, professor, and former CEO of the University of Maryland Medical Center. Harry A Oken, MD, FACP, is an Adjunct Professor of Medicine at the University of Maryland School of Medicine and a general internist in private practice.

Dr. Schimpff is the author of Fixing the Primary Care Crisis – Reclaiming the Patient-Physician Relationship and Returning Healthcare Decisions to You and Your Doctor and Longevity Decoded – The Seven Keys to Healthy Aging. In addition, Dr. Oken and Dr. Schimpff are the authors of BOOM- Boost Your Own Metabolism.

“In the beginner’s mind, there are many possibilities, but in the expert’s view, there are few.”

Shunryu Suzuki

Shunryu Suzuki was writing about Zen beginners and masters, but this concept also applies to the practice of medicine. Experienced physicians are slow to accept a new paradigm, while medical students and new physicians are more open.

Sometimes, what we ‘know’ to be true is not. For example, despite clinical trials to the contrary, it took many years to convince physicians to accept that a lumpectomy could be equivalent and superior to the decades-long approach of radical mastectomy. Similarly, it was long known that premature ventricular beats were associated with a higher risk for fatal heart arrhythmia, and therefore it was logical to suppress them. But when a well-controlled study proved the opposite, medicine could not reject a rational but false paradigm.

Another example – it took decades for the medical community to accept the importance of washing hands to prevent disease. Ignaz Semmelweis, a recent obstetrics graduate, showed in 1847 that childbirth fever could be prevented by handwashing. He did not know that childbirth fever was caused by bacteria so he could not “explain” why handwashing worked. He was largely ignored; some directly mocked him. Semmelweis died in 1865 unappreciated.

Pasteur developed his germ theory of disease in 1860 and Lister advocated an antiseptic approach to surgery in 1867, yet surgeons still did not readily accept handwashing. As late as 1882, President James Garfield died not directly of the assassination attempt but of an infection caused by his doctor’s unwashed hands and forceps.

 In 1979, Australian pathologist Robin Warren noticed the presence of an unusual bacterium in ulcer tissues. His colleague Barry Marshall, a general medicine trainee, discovered that these bacteria [later named Heliobacter pylori] were present in many patients with stomach ulcers. Gastroenterologists at the time were quick to debunk their 1984 article in The Lancet. These experts “knew” that ulcers were caused by stress and genetics leading to an acid imbalance.

                              
Even after a frustrated Dr. Marshall drank a “cocktail” of the bacteria and became ill, the medical community remained unconvinced. It was not until 1994, 10 years after the article was published that the NIH suggested H pylori caused most cases of stomach and duodenal ulcers. Even then, acceptance by the medical community was slow. As historian Daniel Boorstin wrote and Dr. Marshall repeated in his Nobel laureate address, “The greatest obstacle to knowledge is not ignorance; it is the illusion of knowledge.”

While experience can prove extremely useful, especially in medicine, it can blind us to new ideas, even when supported by a preponderance of the evidence. Semmelweis and Marshall were beginning their medical careers and were not set in their knowledge or thought patterns. However, their more ‘expert’ medical colleagues firmly held to their prior experience.

Interestingly, most scientists who become Nobel laureates did the work in the early part of their careers, when they were still “Beginners.” The pandemic has offered us at least one other example – why masks are essential to stop the spread of the coronavirus. As the pandemic began, it was thought by the WHO, the NIH, the CDC, and the Surgeon General, based on decades of dogma, that most transmissions of a respiratory virus are via coughing and perhaps sneezing, producing tiny droplets. These droplets would fall to the ground fairly quickly.

Social distancing would mitigate much of the spread, especially if everyone washed their hands since the droplets might have fallen on surfaces that people touched. In addition, if those who were coughing would cover their mouth or simply stay home, they wouldn’t transmit the infection. There was also a significant shortage of masks, which led to concern that they would be hoarded like toilet paper, leaving an inadequate supply for those working in hospitals with infected patients. So, the advice to civilians was not to wear a mask; it would not help spread the virus.

But there were nonmedical scientists studying aerosols that were challenging these assumptions. They suggested, with data, that much smaller droplets could carry the virus, remain in the air for some time, and spread over longer distances. The recognized experts ignored them. When the aerosol scientists persisted, the experts indicated that there was inadequate science regarding the aerosol concept to warrant recommending masks. “But these are not controlled, randomized trials.” This really meant that the experts were simply not willing to consider other possibilities. The WHO stood firm.

This is a clear example of people with no preconceived notions of how the virus was transmitted figuring out the real answer but were met with stubborn resistance.

Our take. Remember the comment of Dr. Carl Sagan on a common scientific fallacy, “Absence of evidence does not mean evidence of absence,” or just because there is no evidence to prove something does mean that it cannot be true.

Despite the scientific controversy, clear experiments of nature were widely reported in the media that told the correct answer.

What were these experiments of nature? The first was a large meeting of about 175 Biogen senior staff for a strategy meeting in Boston. It took place in a Marriott hotel in February 2020 and included executives from many countries. One person was unknowingly infected. Unfortunately, multiple people became infected, at least 90 in Massachusetts alone, with many others in numerous states and other countries. They, in turn, passed it on so that thousands of infected people were traced back to this one meeting.  

The second experiment of nature was a church choir practice in early March 2020. One member of the choir had a minor “cold” but was not coughing or sneezing. They practiced for about two and a half hours in a space with limited air exchanges. The CDC investigated and found that 53 of the 61 attendees became infected; two died. A third example also occurred early in the pandemic. A Georgia funeral in late February 2020 where there was much hugging and kissing led to many downstream cases. Each of these was amply reported in the media.

Once the evidence accumulated, months after the pandemic was in full force and months after the aerosol engineers, offered their recommendations, the CDC, the NIH, and, reluctantly, the WHO accepted the aerosol concept, which led to the recommendation that we wear masks.

To their credit, the NIH and CDC leaders and the Surgeon General were direct and forceful about the logic and need to wear a mask to prevent spread. For example, Dr. Robert Redfield, director of the CDC, testified before a Senate committee in September 2020, before vaccines were available “…face masks are the most important, powerful public health tool we have. And I will continue to appeal for all Americans, all individuals in our country, to embrace these face coverings. I’ve said it, if we did it for six, eight, 10, 12 weeks, we’d bring this pandemic under control.”

We were directly reminded of this common barrier to medical progress when we treated a woman with what appeared to be classic Crohn’s disease (CD), a potentially severe disease of the gut. It affects more than 700,000 Americans, produces considerable disability, and can lead to severe sequelae, including the need for toxic medications and surgery. Most physicians believe that CD is an uncontrolled inflammation related to an abnormal immune response of an unknown cause.

Despite growing anecdotal information that the disease might be triggered or caused by a contagious organism called Mycobacterium avium paratuberculosis (MAP), very few medical experts are willing to consider this possibility. MAP causes a disease called Johne’s disease (JD), a contagious, chronic, and sometimes fatal infection of the small intestine in ruminants (cows, sheep, and goats) with many similarities to human CD.

MAP enters the milk supply from these animals and is not routinely killed by pasteurization. MAP has been found in numerous patients with CD. Physicians in various countries have treated numerous CD patients with antibiotic combinations with substantial success. Admittedly, one randomized prospective trial in Australia did not find improvement with antibiotics, although that study was later severely criticized for study design, analysis, and sub-therapeutic antibiotic doses.

A recent study by Aitkin et al. found cell-wall-deficient mycobacteria, presumably MAP, in 18 of 18 biopsy samples from Crohn’s patients but none among 15 patients with non-inflammatory bowel disease. The authors observed “the association of cell-wall-deficient mycobacteria in situ with host tissue reactions, and posit this as a cause of the tissue inflammation.”

Our patient, who had been treated for CD by six gastroenterologists, was still experiencing symptoms after undergoing standard treatment that included multiple rounds of potent immune modulator therapies plus surgical removal of an affected portion of her small intestine.

After a serendipitous conversation in which the possibility of MAP as the cause or trigger was raised, she was cultured for MAP and empirically begun on a five-drug antibiotic regimen. Nine weeks later, her blood culture confirmed she had MAP infection. After 18 months of treatment, she has had a total recovery and has been off antibiotics for almost seven years without relapse.   It indeed cannot be claimed that MAP is the cause or the trigger of Crohn’s disease based on anecdotal case reports. Mycobacterial disease is complex, does not always cause symptoms, and

often takes a long time to make itself known. Worldwide, over two billion people have the type of Mycobacterium that causes tuberculosis, but only 10 million have active disease. MAP infections are also years in the making; innate immunity, gut bacteria, and genetics likely play a role in whether or not someone develops a symptomatic infection. MAP likely also causes diseases other than Crohn’s. For example, consider Group A streptococcus, which can be asymptomatic in many people, but causes ‘strep throat’ in others and in a subset can lead to rheumatic heart disease or kidney disease.

One might assume that there is enough intriguing information to encourage others to consider the possibility of MAP. Is this yet another example where experts are trapped in dogma that prevents them from abandoning old theories and considering alternative explanations for diseases of unknown cause? We can only imagine the rapid progress that would ensue if more ‘beginners’ were involved in researching Crohn’s Disease.

Remember Dr. Barry Marshall’s observation, “The greatest obstacle to knowledge is not ignorance; it is the illusion of knowledge,” and the advice of Dr. Carl Sagan, “Absence of evidence does not mean evidence of absence.” Therefore, medicine needs to inspire and nurture, not shun, “Beginners.”