by Ivan Cavicchi
“Unparalleled science, medicine, sick doctors” is the title of my new book just released in the bookstore. The book first raises two fundamental political questions. Since we made the reform in ’78 we have rigorously separated, to the point of structuring a real dichotomy, health care from medicine by substantially reforming the health system, with invariant medicine, delegating health care to politics and medicine to science. Up to now medicine politics has never been substantially interested
28 FEB – My new book is being distributed in bookstores and on the Internet “Unmatched science, medicine sick doctors“(Castelvecchi publisher)
For me, a long onerous job that is not easy that goes on an uphill road full of obstacles and that in the eyes of many honest “health professionals” appears very unattractive, but only because let’s face it, it poses serious problems for change .
I continue to believe, especially after the counter-reform laws of the 90s and after the PNRR, that we in health care have now become a people of ex-reformers and counter-reformers. A gigantic army of dedicated status quo officials.
The book first raises two fundamental political questions.
Since we made the reform in ’78 we have rigorously separated, to the point of structuring a real dichotomy, health care from medicine by substantially reforming the health system, with invariant medicine, delegating health care to politics and medicine to science. Up to now medicine politics has never been substantially interested.
Today with all that has happened and is happening in this society, how is it possible to keep the problems of health care separate from those of medicine? How is it possible today to reduce and simplify the enormous complexities that scientific medicine has in our time, to health problems only? Today after the pandemic, how is it possible that science is just a problem of science alone?
Today the health care professions are in crisis precisely because of the medicine that never changes. How is it possible to face these crises without addressing the strategic issue of medicine, its ways of acting and the reform of practices?
It is necessary to be blind or dishonest not to see that today our society no longer asks only for health, therefore only “the service”, the “performance”, but asks, above all, another medicine, other modalities, other relationships, another kind of practice medical science, a more modern idea of science and with respect to the complexities of the need require other heuristics and obviously other universities.
How is it possible that, even today, the question of a medicine that is adequate to the complexities of the sick, not to the complications of the disease, is not yet in the political reform horizon?
Our scientific medicine behind the glittering showcase of science has huge unresolved questions and a bunch of skeletons in the closet. In some ways we are still stuck with Descartes, that is, with old ways of reasoning.
In chatter we have replaced “illness” with “sick” but in fact our sick person remains more than ever an organic substance and moreover relative to an idea of nature largely superseded first of all by modern science. To this day we are complexity by definition but a true medicine of complexity does not exist.
And then we wonder if patients have become demanding and demanding ones have become hesitant and if the phenomenon of disenchantment with science in this society continues to grow. Is it possible that we still haven’t understood that the use of science in medicine today has become a huge political problem? By now our precious science is evident that in the society of rights it has lost its historical dogmaticity.
The book does an operation that no one has ever done before, but without which we are not going anywhere.
The question I started from is simple: how can I say that medicine is in crisis or has problems or needs to be changed if I do not first define what medicine actually is.
For some, medicine is a scientific discipline, for others it is a technique, for others it is even an art, for still others it is only clinical, for others it is the company where you work, etc.
In reality, I say, medicine is an unparalleled science that is a science that from an epistemic point of view has no equal, made up of different kinds, species, types and forms of knowledge (the main one is the scientific one) with a degree of epistemic complexity especially today among the highest and which is based on an ancient conceptual framework made up of a paradigm to which over time a doctrine has been added, then a discipline and finally a practice.
The book demonstrates two things:
• that in the conceptual framework of our official medicine today there are big aporias and relevant contradictions, therefore significant problems of internal coherence;
• that between the conceptual framework of medicine and society as a whole, there are significant biases that explain a lot of known negative phenomena (which I do not mention).
From this double analysis we get the only sensible thing that in my opinion can be done and that is to roll up your sleeves to remove bias, aporias and contradictions. That is to rethink the system because it is useless to hide the difficulties and ignore it today the real problem is not the details but the system. What we have, for many intuitive reasons, no longer works as before.
And this is the real reason why I strongly argue that today medicine, much before health care, is the real political question.
Finally, the book puts forward a reform proposal which in my opinion alone would solve most of the problems of doctors, professions, practices and services.
Also in this case I start from a couple of simple arguments:
• if medicine is an unparalleled science, it is because its high degree of complexity forces us to use scientific truths (the famous a priori) by integrating, case by case, these truths with the empirical, relational, contextual knowledge possessed by the doctor and the patient;
• if medicine is an incomparable science, it is mainly because the complexity we are talking about alone cannot be in an a priori, that is, it is greater than the a priori, but this means that for the first time the a priori must do space for the doctor’s intellectual autonomy, that is, he must make room for discretionary thinking.
Today the doctor or the operator, whatever you prefer for reasons of complexity and above all for the good of the patient (to be more appropriate not appropriate for the patient) must integrate the a priori he uses, with additional knowledge that only he on the spot can to guarantee.
But if this is true then I say that if medicine is an unparalleled science then the practitioners of medicine for primarily epistemic and only epistemic reasons must be clear, they must have an unparalleled legal status.
This juridical statute must certainly prescribe to the doctor, as it has always done for centuries, what “he must do” but at the same time must recognize what he “can do”, in certain circumstances and in certain cases of course with the necessary guarantees, because in true complexity you normally navigate by sight.
To do this we need a physician trained in complexity who reasonably and responsibly knows how to use the discretionary thinking that the governance of complexity requires.
Today the only one who, under certain conditions, can guarantee the management of complexity in medicine is the doctor.
I’m sorry for the proceduralists (EBMs), but I challenge anyone to call me an unparalleled procedure. An incomparable procedure does not exist. This simply means accepting the principle that complexity is not governed only with a priori but first of all governed by doctors. In other words, complexity is governed only by complexity.
But since I sometimes read in this newspaper proposals to recognize to the medical profession a juridical status that is not incomparable but “special” (old proposal of hospital doctors who years ago asked to be equated with magistrates) I would like to clarify for the avoidance of doubt that for me the statute of doctors (and others) should be:
• unmatched (not special);
• Doctors and others, first of all to be legally unrivaled, should guarantee this society and its citizens an unparalleled science.
The political challenge, therefore, is Peerless science, the real challenge of our time.
If medicine does not commit itself to this society to be unparalleled, what does the patient gain?
I therefore hope that you will read my book and that you will give me a hand in this difficult but certainly necessary battle for reform
Ivan Cavicchi
February 28, 2022
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