Commentary 2

I think Kevork Hopayian, for all his erudition, has got a problem. He is seeing legitimate attempts to improve the scientific understanding of reality as attacks on science itself. Many people, especially people working in general medical practice, find orthodox models inadequate to describe the subtlety, complexity and (in Iona Heath's sense¹) the mystery of face-to-face human experience. This is important today because so many official initiatives and media attitudes are founded on a profoundly unscientific illusion that science can provide definitive answers to human problems. So attempts to improve the models are not merely legitimate but essential if science is to make progress. Hopayian provides here an example of the almost paranoid counter-response of those who see themselves as protectors of the sepulchre of science from heretical attack.

He talks repeatedly of ‘straw men’, but in truth it is he who is setting up ridiculous caricatures simply to knock them down. Gray in his Lancet paper² did not, by any stretch of the imagination, ‘repeat the postmodernist rejection of science’. It is a simplification to assert that postmodernists ‘reject science’ anyway. Nor are there the slightest grounds in Gray's paper for saying that he would stand in front of an oncoming bus, maintaining to the end that it was no more than a ‘social construct’. And nor would any of the other distinguished authors Hopayian attacks and patronises; Chris Burton, Tim Wilson, Tim Holt, Trisha Greenhalgh, and so on — a long list. No-one that Hopayian or we need concern ourselves with is suggesting that an external reality does not exist. But what sensible people are saying is that science goes on and on showing us that the reality that does exist is more complicated than each generation thinks it is.

Similarly, Hopayian is admirable in his description of the scientific method, but utterly wrong to suggest that these methods are disputed by those raising questions about the adequacy of, for example, extrapolations from focused clinical trials (however randomised and meta-analysed such trials may be) to the complexity of human life. As Edward de Bono put it, the left front wheel of a motor car may be excellent, but it is not sufficient.

So this battle of straw men is far removed from the serious matters at issue. But because of the obscurity of the jargon employed it is also a dialogue of the deaf. ‘Postmodern’ for example, although I have used it myself above, seems to be a term permanently immune to comprehension. In Gray's paper, we find ‘pre-modern’ followed by ‘modern’, followed by ‘postmodern’, which makes a kind of chronological sense. But immediately we stumble into the following, ‘… the plight of US health care was examined with a recognition that in the move from postmodern to modern health care something had been lost.’ So, now we are back to modern again! But doesn't every age think it is ‘modern’? Isn't that what modern means? Oh … let's call the whole thing off!

Complexity theory is notoriously jargon-ridden, but Burton's Postcard from the 21st century with which Hopayian takes issue,³ is actually an outstandingly clear explanation of its possible application to healthcare. And so is the BMJ article by Wilson et al.⁴ Both are accessible on the web and I would urge readers to look at them and judge for themselves.

So we need a meeting of minds here, not a false dichotomy. There are enough religious wars in the world already. And we need clear, simple language, rooted in shared experience. Hopayian is, on this evidence, exceedingly able, and a testimony to the expertise that exists within the generalist excellence of general practice. But I think he needs to look at what the authors he takes exception to are trying to say, and then join with them and all of us in the real battle, in which we are allies, not opponents.

That battle is to find a defining line between the kind of ‘mystery’ which Iona Heath talks about,¹ and which is so desperately missing from ‘official’ models of medical practice, and the non-sense (or non-science) of both anti-science and pseudo-science. In my address on science to the College's 50th anniversary symposium,⁵ anti-science and pseudo-science were the two heads of my sea monster Scylla on the one side, and the certainty of fundamentalist science was my whirlpool, Charybdis, on the other. Our task today is to steer a true course between these dangers, and we need people like Hopayian to help us.