Why Iraqi doctors should be interested in research

In spite of the various research difficulties described in the previous article (Why Iraqi doctors are not interested in research), Iraqi doctors should, in my opinion, be interested in research for the following reasons:

1.     Answers to local problems:

Local research even if it is a simple survey sheds light and may produce answers to some local problems. It does not have to produce important discoveries on a worldwide scale. After all, among the huge amount of research published in thousands of medical journals worldwide, very few constitute really important discoveries.

2.     Experience for the future:

With time, research experience accumulates and results are likely to improve.

3.     Education:

Research is highly educating. Knowledge is gained by reading and discussing the subject of research and related subjects. The researcher also learns the ways of obtaining knowledge like searching the internet and using the library.

4.     Promotion of scientific and critical thinking:

By following the scientific method of making a hypothesis, collecting data and modifying the hypothesis, research promotes scientific thinking. The researcher learns how scientific knowledge is obtained and realizes that so called scientific facts are in fact hypotheses with various degrees of convincing power. They are not certainties and that is why they keep changing. This develops in him a skeptical and questioning mind which is important not only in research but also in practice and in life in general. Knowing how various workers frequently differ about the same subject is a warning that one should not take everything he reads in a book or a journal or hears in a lecture as established facts.

5.     Reflection on practice

a.     The scientific method is not confined to research. It should be the basis of practice too. In fact the clinician is involved in research daily by trying to make a diagnosis of his patient’s illness and find solutions for his problems. Fever in a patient, for example, is a scientific problem. A hypothesis about its cause should be made after the initial information. Data is then collected through history taking, physical examination and various tests to strengthen or modify the hypothesis once or more times. Actions are then taken on the basis of the final hypothesis. This is what the scientific method is all about.

b.     Awareness of observer error and observer bias, common precautions in research, is reflected on interpretation of clinical findings and various tests made during daily work.

c.      Awareness that association is not necessarily causation, a common precaution in research, reflects on clinical work. Jaundice in a patient with a positive hepatitis virus BsAg is not necessarily caused by hepatitis B virus.

d.     Knowing how reference values are obtained makes interpretation of patients’ figures more intelligent. You may e.g. accept a figure slightly outside the reference range because you know that 5% of normal people are so.

e.      Research improves logic and shows its limitations. Treatment of various illnesses is based on trials done on a number of patients somewhere in the world and the results are generalized to include all patients all over the world (induction in logical terms). Why should your patient behaves in the same way as those patients?! In fact induction is the logical basis of most medical knowledge, not only treatment. One should therefore not be surprised to find so many differences between practice and the book. What should be surprising is the presence of so many similarities!

Why Iraqi doctors are not interested in research

Iraqi doctors are generally not interested in doing research. Many have a negative attitude towards it and argue that:

1.  Time spent in research is better spent in patient care.
2.  In our poorly developed situation, research is unlikely to produce significant results. Important discoveries have been made and can only be made in developed countries that have the facilities and the expertise.

These are some possible reasons for the lack of interest and the negative attitude:

1.      Lack of experience:
Most doctors lack the necessary experience:

a.       They were not involved in research during their training, unlike doctors in developed countries who get involved in research done by those who supervise their training.

b.      Most professional postgraduate degrees in clinical branches, including those from developed countries, do not include research in their requirements. (There are exceptions like the certificate of the Iraqi Board of Medical Specialties.)

c.       Earlier education in Iraq in primary and secondary schools is generally based on memorizing (one of the Arabic words commonly used to mean study is “istithkar أستذكار” which means remembering). Thinking and reasoning do not have prominent roles. The student becomes used to accepting what he is told rather than developing a skeptical exploring mind which is the basis for research.

2.      Lack of time:
Doctors are usually busy people. Their time is occupied by care of patients in government institutions and in private practice.

3.      Lack of incentive:

a.       Research is not financially rewarding.

b.      Except in universities, it does not promote the position of the doctor in the place where he or she works.

c.       Most of the problems in medical practice in the country are not medical. They are administrative, political, cultural and financial. These are less likely to be solved by medical research.

4.      Difficulties in research:

a.       Research is time consuming and mentally demanding.

b.      Technical facilities (laboratories, radiology etc.) in our hospitals and medical institutions are not satisfactory.

c.       There is no good medical record keeping and good follow up of patients.

d.      Good libraries and references are not widely available.

e.       There is no sufficient funding for research.

f.       Cooperation of patients and non medical people is generally poor. Importance of research is not widely recognized in our culture.

g.        Animal research is not generally available except on a very limited scale in universities.

h.      Ethical and legal restrictions on research on humans are not well defined and properly legislated and not carefully observed. This can create problems which may sometimes be serious.

Readers may be able to add other reasons that I may have missed.

Our concept of disease entities

There is no sharp line between health and disease. (See a previous post in this blog “The concept of health and disease” please). Deviations from what we consider as “normal” that are detrimental to the individual are labeled as illnesses or diseases. The ways in which a person’s condition deviates from normality take innumerable forms and shapes. Every patient’s disease is in fact unique. There are similarities and differences between diseases of different individuals. Because we think that similar diseases may progress in similar ways and respond to our intervention in similar ways we try to group them into one disease entity and give it a name. There are grades of similarity between the individuals in the same disease entity. We might see patients whose diseases fit very well with the classical description of that entity and patients whose diseases differ from the classical description to various degrees. There are no sharp lines of separation between disease entities. Some diseases may not fit well into any of the artificial entities that we create or fall in the boundary between two entities or more.  We then either force them into one of the entities that we consider the nearest possible or include them into more than one entity or create a new entity with a different name to accommodate them.

These facts explain at least partly the differences between doctors about the diagnosis of a patient’s disease and why in many instances a patient’s disease does not behave in the way we expect it to.

Much of the controversy in medical discussions is about language rather than fact. It is semantics. Nevertheless it is important because language dictates our acquisition of knowledge. It is the language, the names, that makes it possible for us to learn about diseases and to get the help of the book or the literature to guide our prediction of prognosis and our management. It is not an ideal situation but that is the case with almost everything in life.

Notes on treatment of hypertension

The border between health and disease

The concept of health and disease, in the minds of most people and many doctors, is simple and clear cut. A person is healthy if he has no disease. Diseases are well defined and clearly recognizable conditions.

The reality is not so. Health is not the same in all so called healthy people. It covers a wide spectrum of conditions physically, mentally, and socially. Some people are physically robust, happy, psychologically satisfied, and socially integrated and active. Others are frail, easily tired, worried, frequently unhappy and socially isolated. And there are all grades in between. That is why the aim of medicine is not only to prevent or treat disease but also to promote health.

Apart from acute conditions like acute infections and trauma, the transition between health and disease is gradual and ill defined. Most symptoms of disease are present to some degree in so called normal people. All people become short of breath if they exercise sufficiently and "sufficiently" varies in various people. Some may need to climb fifty stairs to become short of breath. Others may become so after climbing thirty or twenty stairs and so on. People with heart or lung disease may become short of breath on climbing ten stairs or one or two depending on the severity of their illness. What is the number of stairs that makes shortness of breath pathological? Can we put a definite figure? You can say the same about poor appetite, headache, anxiety, numbness, poor memory, readiness to fall asleep on going to bed, muscle and joint pains and so on. Recognizing a symptom as abnormal or pathological varies widely between people. That is one of the reasons why some people go to the doctor frequently and sometimes for no good reason, while others do not go unless they become severely ill.

A similar thing can be said about laboratory tests, but in this case artificial, statistically derived, boundaries have been created by putting a reference range for every test. These reference ranges have come to be generally conceived as the boundaries between normal and abnormal test results. According to these boundaries, a test result can deviate from the average of normal people to a large extent and still be considered normal. Then when it crosses the artificially drawn boundary it suddenly comes to be regarded abnormal!! The transfer from health to disease is not that sharp in real life.

The spectrum of health is wide and so is that of disease and the border between the two is frequently blurred and difficult to discern.