Taken from the German Romanticists, the term zeitgeist [literally "time-spirit] is a massive concept meant to depict the overall cultural, intellectual, political and/or spiritual climate within a defined group.1 Implicit in the term is the fact that change is inevitable, so that whatever mores (social or scientific) were applied yesterday may not necessarily be the rule today.
In the opening minutes of the classic Woody Allen film "Sleeper," for example, we find the protagonist Miles Monroe perfectly preserved into the future by means of cryogenic freezing. The gowned surgeons carefully unwrapping the awakening body exclaim that Miles has just asked for a breakfast of wheat germ, which, "some years ago was felt to contain life-preserving properties ... precisely the opposite of what we know now to be true."2
In a more serious vein, medical history is fraught with complete reversals of belief over time, such as:
- Use of leeches: versatile in the 19th century, then considered to be a slimy bloodsucker, now used to treat arthritis.3-4
- Breast-feeding: universal throughout history until formulas came into vogue during World War II; now re-emerging.3
- Electroshock therapy: formerly very common, then fell out of favor in the 1970s and now re-emerging.3
- Botox: once a taboo and now a fad in skin treatment.3
- Fats: once considered a major cardiovascular risk factor, now desirable in small quantities.5
- Hand-washing: once thought to be unproductive and which cost Ignaz Semmelweis his position at the University of Vienna Hospital in the 1850s, this practice has since been found to be essential for maintaining surgical sterility and reducing the incidence of hospital-borne infections.6
- The initial rejection of Edward Jenner's smallpox vaccine, held by the Royal Society of Medicine to be "so much at variance with established knowledge, and withal so incredible."6
- Peptic ulcers: blamed in a 1967 review to be the consequence of being raised in a family with a dominant mother and passive father,7 but ultimately traced to the bacterial species Heliobacter pylori by the Nobel-Prize-winning research of Barry Marshall - revolutionizing our entire outlook upon this condition and how to treat it.
What does all this mean in terms of conventional concepts of "evidence-based medicine"? Simply that cultural authority undergoes shifts with time that do not necessarily move at the same rate at which credible research is produced. By this I mean that even the most robust research results, such as those produced by Dr. Marshall, took decades to be accepted in standard practice.7 Rumor has it that it took an article in National Enquirer to finally drive the bacterial model of ulcers into widespread public awareness.
Consider that in the space of just about a decade, health policy-makers have begun to move away from a base of only randomized clinical trials and meta-analyses to a triad of decision-drivers that also includes clinical judgment from experience8 and the empowerment of the patient through their values, expectations and requests. This is precisely why the term evidence-based medicine has only recently fallen out of favor, being replaced by the moniker, evidence-informed medicine.9-10
Probably one of the best examples of the mellowing of oppositional thinking applies to the case study. This is an example of a clinical experimental design which, by convention, was relegated to the lowest, untouchable caste of the traditional pyramid of rigor of clinical research methods. Here, with a series of quotes from the American social scientist Donald Campbell, we take a front-row seat in witnessing the greening of what was once an originally hostile reaction toward case studies:
- 1963: "Such studies have a total absence of control as to be of no scientific value."11
- 1979: "Certainly the case study as normally practiced should not be demeaned as identification with the one-group posttest-only design."12
- 1989: "More and more I have come to the conclusion that the core of the scientific method is not experimentation per se, but rather the strategy connoted by phrase, 'plausible rival hypotheses.' ... We should use those singular event case studies [which can never be replicated] to their fullest, but we should also be alert for opportunities to do intentionally replicated studies. ... I like to believe that this shift was facilitated by ... laboratory research on that most hard-to-specify stimulus, the human face, and that this experience provided awareness of the crucial role of pattern and context in achieving knowledge."13
It's the pattern and context that is the smoking gun here in providing a clue as to how values and standards can shift in a sea of social attitudes. With this said, the opposition by which certain concepts of holistic medicine (existing and yet to be introduced) are met may very well be overcome not with just research evidence (which is needed), but with the more nebulous concept of social adaptation. Therefore, it may not be totally out of line to propose that the next, arguably more real-world criterion by which any clinical decision is actually made will be driven by zeitgeist as well as by published research evidence.
References
- Wikipedia. Zeitgeist: definition, description and relevance. en.wikipedia.org/wiki/Zeitgeist.
- Transcript of "Sleeper." Accessed from www.script-o-rama.com, June 25, 2010.
- Patchett A. "Estrogen, After a Fashion." The New York Times Magazine, July 28, 2002:11-12.
- Michaelsen A, et al. Leech therapy for symptomatic treatment of knee osteoarthritis. Alternative Therapies in Health and Medicine, 2002;8(5):84-88.
- Schersten T. "Dietary Fats and Cholesterol--Facts and Myths." Scandinavian Cardiovascular Journal, 2008; 42(4): 325.
- Hyman M. "Paradigm Shift: The End of 'Normal Science' in Medicine: Alternative Therapies in Health and Medicine, 2004;10(5):90-94.
- Susser M. Causes of peptic ulcer: a selective epidemiological review. Journal of Chronic Diseases, 1967;20:435-456.
- Sackett DL. "Evidence-Based Medicine." Seminars in Perinatology, 1997;21:3-5.
- Fisher CG, Wood KB. Introduction to and techniques of evidence-based medicine. Spine, 2007;32(19S):S66-S72.
- Glasziou P. "Evidence-Based Medicine: Does It Make a Difference? Make It Evidence Informed Practice With a Little Wisdom." (Letter) British Medical Journal, Jan. 8, 2005;330(7482):92, discussion 94.
- Campbell D, Stanley J. Experimental and Quasi Experimental Designs for Research. Boston, MA: Houghton Mifflin, 1963.
- Cook T, Campbell D. Quasi-Experimental Design and Analysis Issues for Field Settings. Boston, MA: Houghton Mifflin, 1979.
- Campbell D. Introduction. In Yin RK. Case Study Research: Design and Methods. Beverly Hills, CA: Sage, 1989.
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