What’s been happening ?

Claude Bernard lives on – or rather his principles. The ones I always admired and still try to emulate was his emphasis on doubt, the need for proof and ethical conduct – especially as applied to research and medical practice. These have led me to dwell on the drug treatment of cancer that has spread – the so-called metastatic disease that is now the commonest cause of death in many societies. Its treatment is beset with uncertainties. The vulnerable public often wish for and hope for any prolongation of their life and at any expense – physical and financial. They are the victims of a greedy medical industrial complex that embraces pharma, government, oncologists and the media. I am committing the last part of my life to an attempt at mitigating this powerful influence which is overwhelmingly anti-ethical.

I have crystallized my perception of the problem in an analysis which has just been published in the British Medical Journal – entitled ‘Cancer Drugs – survival and ethics’.

http://www.bmj.com/content/355/bmj.i5792?utm_medium=email&utm_campaign_name=201611316&utm_source=etoc_weekly

The response has been extraordinary, the Altmetrics score of 1350 putting it into the top 1% of attention-grabbing articles ever published. This response has added fuel to my fire, and I will be examining approaches that could put the drug treatment of metastatic disease on an ethically more acceptable plane.

Watch this space…….

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More about Bernard ? Surely not !

What is there left to say about this remarkable man, who has occupied my thoughts and my pen (well, computer actually) for the last seven years?  During 2013 (his bicentenary), my presentations to a wide variety of audiences in France and Switzerland have provided a lot of useful feedback – and large book sales !!!  My final two articles – one on Bernard himself, the other on his relationship with Louis Pasteur have just been published, and in the next week or so I will post the texts here – unfortunately for my anglophone friends they were published in French (although I will locate the original English manuscripts for this site) !!    It could have been otherwise, but my colleagues in the UK seem not to be interested enough in Bernard’s contributions and above all, his always-relevant train of thought and his principles. Tant pis – as they say here in France.

What next?  There is a lot in the back of my mind, but foremost is the idea that science can be richly applied to the arts – practically and creatively – and vice versa. Those of you who have read my book will know that I fantasized dialogues on this subject between CB and Princesse Mathilde, cousin to Louis Napoleon (IIIrd) . Mathilde was the ‘patroness of the arts’ in the mid 19thC when CB was a guest at the Palace of Compiegne, just outside Paris. We’ll see. 

As you will also remember, Emile Zola took a leaf out of Bernard’s historical masterpiece and applied  ‘scientific determinism’ to (naturaliste) literature: he founded a short dynasty of such writers. Now, Zola would surely be an interesting character to write about, but his eccentricities have been well enough documented. Did you know that he was also, quite unknowingly, the link between Bernard and the foundation of the state of Israel?  It’s true.

I guess that the most interesting comment on my talks came from an industrialist who attended my lecture in Macon – in the Burgundy wine-growing area. There I was talking of CB’s milieu interieur to a highly educated but not academic audience in the Academie. The gentleman in question commented that this important concept of stability and protection of the body’s interior was applicable – and had actually been applied – to commercial and industrial settings. That too has given me considerable food for thought…..and perhaps even for writing……..

Do keep in touch…..

 

 

 

What is literature ?

A comment from a retired professor of literature about my last blog has sparked today’s entry. The lady in question maintains that no form of scientific writing or health-related presentation can have ‘literary’ value: it should be simply referred to as ‘communication’. Of course, this comment was in response to my explicit admiration of Claude Bernard’s public writing and presentation skills. We know that people came from the world over to hear him speak: that he was invited to write material for popular science magazines. Above all, we know that his seat in the Académie Française – the prestigious sanctuary of the French language and ‘belles lettres’ – was awarded less for his science than for the manner in which he wrote his articles – and particularly his ‘Introduction to the Study of Experimental Medicine’.

Where do we go from here? Certainly, there is a view that scientific writing for the public (fr: vulgarisation) is a distinct genre littéraire (http://master-cs.u-strasbg.fr/IMG/doc/art-bj.doc). Beyond this, I believe that even articles destined for the desks of other scientists need to be made more easily readable and comprehensible: I rarely found the dry, factual writing of medical articles attractive: to read them was an obligation, a necessary evil.

We surely want our patients to understand what we advise, and even on what grounds we advise it. Is there any reason why they should not access and understand original medico-scientific articles? To say that they are ‘above their heads’ is surely patronising and begs the question of whether they have a right to access the source material on which their doctor bases his or her treatment. Please do not suggest ‘dumbing down’ (a horrible phrase) a scientific paper for public consumption: that is overtly condescending. Good clear speaking and writing is in my view an obligation of anyone wishing to convey an idea, a result or a conclusion to anyone else.

What do you think?
PW

Bernard – the communicator

Funeral

After a recent talk that I gave about Bernard, quite a few people showed interest in this sketch of his (state) funeral in Paris in 1878. A cortege of some 4000 mourners had followed him to his final resting place in the cemetery of Pere Lachaise. The very next day, Le Figaro reported the occasion, commenting that “…all Paris wept…”

Would this happen today if an equally famous scientist died? I think not, and let me explain.

Quite apart from the brilliance of his discoveries, Bernard was a fine communicator. He loved writing, had an imaginative mind, and in his early years had embarked on a literary career which was brought to an abrupt halt by Saint Marc Girardin, the harsh but well-meaning critic who steered him towards medicine. Later, Bernard’s research was largely based at the College de France, where he was also obliged to lecture on his research. A centuries-old decree of the College declares that the public should have free access to all its lectures. Accordingly, those who give them are obliged to make their presentations readily understood. The French term vulgarisateur is still used to describe lecturers who achieve standing in this art, and there were – and still are – many of them. Indeed, the French have always laid emphasis on educating the grand public. It was the brief of successive ministers of ‘public instruction’ to ensure that this ethos was maintained. During  the 19th century, Louis Napoleon was particularly keen on the concept and personally endorsed Bernard’s capacity as a communicator.

In addition, that century had ushered in a hunger for written knowledge. Daily newspapers reported medical advances which were explained in fine, but still easily understood detail – and not just those advances that were simply sensational. Weekly publications like l’Illustration also followed this trend, while other journals like La Revue des Deux Mondes actually invited physicians and scientists (as well as other academics) to submit reviews on subjects of general interest. Claude Bernard, with his capacity both for good, simple writing and for rhetoric was  born into, and thrived under this culture – and so the public certainly knew about him!

Science has become more complex, and then again more relevant to everyday life. More than ever – and despite television, the Internet and the ever-useful Wikipedia – there is a need for this verbal process to be maintained and extended beyond its birthplace in France (incidentally, we also need an English equivalent for the term vulgarisateur).

Finally, medical schools spend far too little time teaching students how to communicate to patients the nature of their condition, their responsibility in its management and the limits of their medication.  I am convinced that physicians more oriented towards this type of communication will have better outcomes in their patients. Some years ago, I enlisted the help of my colleagues in different specialties to compile a computer database of information leaflets on a wide range of disease entities. These were specifically designed for physicians to help their patients to understand their conditions. PatientWise went on-line and a computer-based version is still available from various internet suppliers.

PW

What did the writers Rabelais, John Keats, Anton Chekhov, Arthur Conan Doyle, Somerset Maugham, Axel Munthe, Michael Crichton and Richard Gordon have in common?

They were all physicians. Indeed, there are societies of medical authors in many countries, and physician-writers even have a Wikipedia entry –http://en.wikipedia.org/wiki/Physician_writer).

Claude Bernard is not listed, although in his late teens he wrote his play Rose du Rhone, which was successful enough to provide the money for him to move to Paris from his native Beaujolais: he wanted to woo the world of drama with his new five-act Arthur de Bretagne. Harshly put in his place by the eminent drama critic, Saint Marc Girardin, he was steered towards medical studies. Not that much later, the sheer eloquence of his scientific presentations drew crowds from all corners of the globe to his public lectures at the Collège de France. He was soon invited to write for the illustrious Revue des Deux Mondes. His crowning glory was election to the Académie Française : not so much for his science, but for the literary quality of his copious written output, including his almost biblical reference book, the Introduction to the Study of Experimental Medicine.

The interested can find all this detailed in my novel, A Matter of Doubt  http://tinyurl.com/matterofdoubt It also forms the subject of my talk, Claude Bernard extraordinaire – scientifique et littéraire at the Médiathèque of Monaco on May 2nd at 18.00.

The nature of the link between medicine and literary ability is highly complex and is much debated. However, the discipline of Medical Humanities has evolved from the link, with the realization that literacy contributes to the performance and the understanding of physicians – http://medhum.med.nyu.edu/.

PW

…and what are PIM’s?

This blog was prompted by an email I received last week from a reader. “Did Bernard…” she wrote, “…make any direct contribution to human wellbeing”.

Imbued with the philosophy of René Descartes – that one should always doubt and then search for proof, Bernard was a fully-qualified doctor who then refused to practise medicine. His basic tenet was that most medicines at the time were ineffective or of unproven value. “Current treatments are nothing more than human experimentation…” he said, “…I prefer to experiment on animals.”

In his lectures to medical students, he insisted on avoiding guesswork and tradition in the choice of therapies: their value had to be proved before being used. He also emphasized that all medications were potentially poisons, especially if taken in higher doses. Conversely, he also showed that many poisons used in smaller doses could prove to be valuable medicaments.  Above all, he enlarged on the teaching of his one-time master, François Magendie. When asked by junior doctors what medication they could prescribe he often replied: “Have you tried doing nothing?”

Indeed many illnesses – and particularly in the young – are self-limiting.

Potentially Inappropriate Medications (PIMs) are a topical subject, and the use of multiple medication (polypharmacy) is particularly common in the over-65 age group. A few years ago Garfinkel and his colleagues in Israel discontinued on average 3 drugs per patient in half the residents of a nursing home. Over the next year this half survived twice as long as the other half whose treatment had been unchanged. Also during this year, acute problems arose only half as often in the first group as in the other residents.

Over-subscribing is rife throughout the world – it is costly, and above all dangerous.

I think you would agree that Bernard contributed grandly to human wellbeing – if only we had listened!

PW

Diabetes – a two-edged sword?

Diabetes was the only specific disease to which Bernard committed his research: all his other work – such as on poisons, on fermentation and on the chemical balance of the body (le milieu intérieur) were phenomena which he targeted in order to understand the normal functioning of the body: in his eyes the essential first step towards understanding its malfunction. The reason for his focus on diabetes is not clear from any of his writings. He probably saw it as a prime example of ‘spontaneous physiological dysfunction’.

And so it has remained for 150 years.

Part genetically determined, part environmental, we still do not really know why it occurs, nor exactly how the inherited and environmental factors inter-relate. In particular, we do not understand why diabetes prevalence in the population varies from one percent (eg Alaskan Eskimos) to forty percent (eg Pima Indians and Nauruans). What does this enormous variation tell us? Neither nutritional levels nor the degree of obesity entirely explain it – even though increasing prevalence of obesity is the most important cause of the current almost epidemic explosion of diabetes across the world.

Exactly 50 years ago, the geneticist JV Neel suggested that the gene(s) responsible for diabetes carried a survival advantage under conditions of famine – that those without ‘diabetic’ genes were more likely to die from starvation – that those with the genes had the advantage of storing calories.  (see ‘thrifty genotype hypothesis’ entry in Wikipedia). In evolutionary terms, Neel’s hypothesis proposes that one or more genes promote selective survival of that sub-section of the community and thus contribute to the survival of the community as a whole.

In my own research 40 years ago, I showed that animals from more arid, food-spare regions (eg deserts) were more likely to become diabetic in captivity. I also found that when fasted, they were able to ‘economise’ by reducing their metabolic rate. Therefore they maintained their weight when challenged by fasting – and were also more resistant to high environmental temperatures. In addition, running low blood sugar  levels causes infertility (at least in rats and rabbits!): accordingly, any biological system which allows the blood sugar to run at rather higher levels should help to maintain the fertility level of that species.

Some years later, I was not surprised when my field studies showed that more than 30 percent of Australian aboriginals – originally nomadic hunter-gatherers in the heart of Australia but now living in urbanized society – had diabetes. Was it their diabetic gene(s) that had allowed them to (selectively) survive millenia of relative food scarcity? Do ‘diabetic genes’ indeed confer a survival advantage  – under the right conditions?  Natural selection was only proposed by Charles Darwin during the latter part of Bernard’s life, but Neel’s theory slots neatly into the concept of ‘survival of the fittest’. Notwithstanding a whole host of parallel theories on the fundamental nature of diabetes, it is an interesting concept worth preserving until something more conclusive comes along.

PW