Big Picture medicine
It is an obvious fact that the whole picture tells you what is happening more accurately than a tiny fragment of an image.
. If we look at things only in isolated parts, we risk misinterpreting our reality.
In medicine, this means looking at the biopsychosocial context of humans and disease.
It’s not just about what happens at a cellular level - it’s also about what happens in real life.
What level of science should we look at in order to understand our bodies and our world?
In medicine, our health and wellness can be studied from different perspectives.
We can look at things from a cellular level (i.e. are there changes in our cells when we are depressed?), at an organ level (i.e. are there changes in the brain when we are depressed?), and at a whole-person level (i.e. are there changes in ourselves and our environment when we are depressed?).
In other words, you can look at something microscopically, big picture, and anywhere in between. Where ever you look, you will find patterns that become your answers.
The real question is - where does the problem begin? Is it a cellular problem that turns into a whole-person problem? Or, is it something at the whole-person level that translates into changes in our cells as a result? Which came first, the chicken or the egg?
Most likely, the feedback is bi-directional, meaning that all the levels influence each other. No one level is in charge.
What is perhaps most important then, is to look at the level where you have the most control, as these answers will be the most helpful in our every day lives.
This means looking at the whole-person level, since we have more conscious control over ourselves than we do the mitochondria in our cells.
Anything that is real cannot be described with words alone.
Constructivist approach to truth: The more viewpoints (perspectives, values, opinions, observations) that are considered, the more fully we are able to know our world.
Close your eyes. See how dark it is? Now chose which direction to turn your head, what angle, and how much you wish to open your eyes. What do you see? You see part of the room around you, perhaps blurry if your eyes are still partially closed. This is what you see, because of the choices you made. This is what you would report is out there.
The same process echos in research. If we are in the dark on a particular subject – perhaps how to treat dementia – we look around to find the answer. Where we look (which treatments to study), and how (which methods to use), are decisions we make based on who we are, and who we are is made up of what we value. Thus, the facts we find from this experimentation will be true – but only for those with the same point of view. And we will not have the whole picture, unless we look in different ways, at different angles, through different eyes. Otherwise, we will only see one small part of the room.
I agree with the positivist approach that there is a world external to us that we can know, but only as a collective conscious. It is not possible for any one human to grasp the entirety of the world, of what is. Only the sum of our views will illuminate the truth of our external reality.
We can know with great certainty (statistically depicted as a narrow confidence interval) to what extent the patient given the intervention in the exact conditions of the trial will have the outcome. However, most people are not that trial patient (single vs multi-morbidity) and the trial context will likely never be found again (the exact trial nurse that called the patient to check in was an intervention in and of themselves). So, while we can know with certainty what is true in a fixed context, it does not help us chart a course in the real world, which is inherently multi-contextual. To have transferable knowledge, we can build on the certainty of systematic reviews and layer other forms of knowledge (narrative reviews, qualitative studies, case reports) to create a broad, holistic view that is transferable into the wider world. Expert opinion is actually the culmination of all forms of evidence that is used in the individual physician-patient interaction. We thus find knowledge that is transferable outside of a specific context; although statistical precision may be lost, reality is found.
Imagine we each have a flashlight, with which to explore the world. Where we chose to point it, at what angle, with what intensity, will all affect what we find – these choices are our values. With our flashlight we may then see what is before us, but only in partial relief – shadows remain, as our own flashlight is not powerful enough to illuminate all that is. However, if you have multiple flashlights – each directed again by our individual choices (values) – we can illuminate the world external to us from multiple angles, and bring what is into sharp relief. The brighter the light, the more clearly we see. This is why it is not only acceptable to have multiple viewpoints (values), it is necessary to know the world as it truly is. If our search is for absolute truth, this is the only way. If our search is only for our own unique viewpoint, as might be the case for forming personal beliefs, then using just your own flashlight will do.
What if someone has a stronger flashlight? They would have more influence over what is deemed to be real. This is where power comes in. Those who can afford to run their flashlight at all times, buy perhaps multiple flashlights from others to point in the direction they chose, they will dictate the world to align with their views. In this way, the values of the powerful can overshadow the masses; the powerful dictate our views.
The reality flashlight is not hierarchical, unlike the EBM pyramid upon which it is based. By flipping the pyramid on its side, we can see that knowledge exists as a continuum, with different strengths and weaknesses. To get to reality, we need the entire stream of light; you cannot cut the light off at the source (the systematic reviews), nor would you want to truncate the light source before it ends (remove expert opinions). As the light disperses towards the end you the greatest pool of light with which to view.