Richard Lehman: The Medical Reformation

richard_lehmanThe Reformation that we know best began some time after the year 1500, but had its roots in a technological revolution, which took place 50 years earlier—the invention of the printing press.

Then (1450-1500): Thanks to the printing press, the Holy Scriptures became widely available in Latin. But ordinary people could not read them, and scholars began to find that they were not very accurately translated.
Now (1990-present): Thanks to the internet, randomised controlled trials and systematic reviews are widely available, but ordinary people do not read them and scholars find many inconsistencies and gaps.

Then (1500-1520): A group of scholars (e.g. Colet, Erasmus, etc) attempted more accurate translations of the Scriptures and the Fathers, but began to cast doubt on the relevance of current theological discourse and religious ceremonial.
Now (1990s): A group of scholars (e.g. Chalmers, Sackett, etc) attempted more accurate collation of the evidence, and cast doubt on the way that it was being translated into effective clinical practice.

Then (1515-1525): A number of reformers grew impatient with the obsession of the Church with worldly power and wealth. Most were in favour of gradual transformation, beginning with the worst abuses. All were in favour of a more personalised religion, in which individual believers understood the scriptures and took a real part in worship. But Martin Luther wanted a radical departure from the past and rejected compromise with the Papacy, which he wished to see destroyed.

Now (2000 onwards, especially 2013-present): A number of reformers felt that the pharmaceutical and devices industry was growing all powerful—setting the agenda for academe and distorting clinical practice. Most were in favour of gradual transformation, beginning with the worst abuses. All were in favour of a more personalised medicine, in which individuals could express their preferences and take a real part in decision making. But some want a radical departure from the past, and see industry and its academic partners as a criminal conspiracy.

Then (1520-1540): The old order began to fall apart. Many in the church hierarchy (priests) accepted the new ideas, but those in command saw them as a grave threat. The princes and kings of Europe reacted cautiously, while the reformers wooed them by proposing the ideal of a Christian Prince who was sovereign over both the people and the Church. And the reformers began to argue among themselves. They wrote copiously: large books, small books, tracts, letters, table talk, orders of worship, and hymns. These were avidly circulated and read, but led to divisions of creed and practice.

Now (2014): The old order is falling apart. Many in the health professions accept the new ideals of open data and shared decision making, but the academic leadership is worried about loss of “intellectual property,” along with the familiar funding streams and career progression through publication. The rich and powerful medical industries are in the process of allowing access to data, and are re-examining their links with academe. Reformers argue among themselves about how radical an approach to adopt towards industry and academe. They write books, articles, blogs, tweets, and guidelines.

Then (1530-1680): Europe is torn apart by constant religious war and persecution for a century and a half. The papacy reacts with a Counter-Reformation, and the kings and princes show constant changes of allegiance. Whole populations are expelled or forcibly converted. Those caught in between—e.g. Jews and Baptists—are killed. Populations are forced to conform to the beliefs of their rulers. There are a few cases of tolerance: the Netherlands, Poland, and eventually England. Two hundred and fifty years after the Reformation began, the United States of America becomes a universal refuge (slaves excepted) and the first secular republic.

Now (2014): There can be no catastrophic ending to the Medical Reformation, but there can be a prolonged, messy period of change, with much needless bickering and duplication of effort. That is why the medical reformers must all work together towards the common goal of dependable, real time, patient relevant evidence, which is brought to bear through effective shared decision making. This is bigger than any individual, and will last longer.

Richard Lehman is a senior research fellow at the department of primary healthcare at the University of Oxford. He was a full time GP for 32 years.