Medicine as a guild

Only recently, with the reflection time provided by the onset of disability retirement, and with the prodding of Robin Hanson’s posts on Overcoming Bias, I realized that the practice of medicine is not a science. It’s closer to a “guild”.

The art of medicine is a well-known cliche, apparently referring to the use of one’s “clinical judgment”. Such judgment, to a great degree, is anecdotal, based both on individual experiences and that of our mentors. These mentors, or their peers, hold the power to determine the student’s eligibility for guild membership, and as one would expect, their customs and belief systems are parroted back to them. Yet our medical dean told us as freshmen: “In order of increasing unreliability, there are lies, damn lies, statistics, and anecdotes.” The practice of medicine involves a lot of science, but at best, it’s a hybrid. Its guild characteristics are undeniable (it’s my blog: with possession comes privilege), with exclusive selection requirements, rights of membership, and extensive turf-protection mechanisms. I touched on this in the maiden post for this blog.

In The Pillars of the Earth, author Ken Follett gives a spellbinding description of the working of stonemason guilds as they shaped the cathedrals of the Middle Ages. In their illiterate society, there was no general public review of the veracity of construction principles. The masons used the secrets of their society to produce results that spoke for themselves. For the most part, the reason that keystones enabled arches was immaterial, and almost surely not understood. Nonetheless, their use made cathedrals that are standing today. The anecdotal knowledge and the power derived from the exclusivity of the guild allowed these artisans to negotiate a better lifestyle for themselves than that of most of the other worshippers in their creations. I dare-say there was an element of great pride in their skills, as well. I double dare-say there was an element of jealousy and resentment in intelligent non-guild members. I triple dare-say that the rate of advancement of building techniques would have accelerated if other intelligent members of the society had been allowed critical input.

Recently, I was involved in the comments on a couple of blog posts that are quite revealing about the “art” aspect of medical practice: here, by Dr. David J. Balan, a prominent economist, and here, by Dr. Seth Roberts, a prominent psychologist. In both cases, intelligent members of guilds not associated with the guild of medicine were given medical advice. In each case, they asked for rational evidence to support the recommendation. In each case, they were told that such evidence existed and that it confirmed the sagacity of the advice. In both cases, the doctors were wrong (about the existence of evidence). They knew that a keystone facilitated an arch, but they weren’t sure why. That’s not science. This sort of encounter is becoming more common among doctors and their patients of equal or superior intelligence. The medical guild has published all their information on the Internet. Good for the patients, bad for the guild. The next thing you know, the patients will want limited guild-privileges to treat themselves. Actually, they’ve already voiced this opinion. And since the margin of elective US medical care is zero maybe they have a point.