SOME THOUGHTS ON NORMAL, OR STANDARD, VALUES IN CLINICAL MEDICINE

Abstract

Clinical medicine, for all its achievements, is built on the logically inconsistent dichotomy of health and disease. Our first function as physicians is somehow to decide whether a patient belongs in an ill-defined category of healthy individuals, or to the general class of nonhealthy individuals. Unless we are content to act on general impressions, we proceed by first dismembering the patient bit by bit until he is not a person at all, but rather an association in time and place of assorted discrete attributes or characteristics. Each of these attributes is considered as being normal or not, either separately or in relation to a few others. If the right combination of abnormal attributes can be found, the patient is then re-assembled as a member of a particular class of previously defined diseases, or becomes the first member of a new class. If no such combination is apparent, he is reborn as healthy, at least for the present. My apparent facetiousness is not intended to obscure the fundamental fact that we have not found any other satisfactory way to arrive at intelligent decisions. On the contrary, in the historic development of quantitative medicine, we have deliberately cultivated just this approach in contrast to the impressionistic approach. With ever increasing numbers of attributes becoming available for forming judgments, the responsibility for understanding what we are doing becomes greater and greater, both for those who elect to define these attributes and for those who plan to use them in the conduct of medical practice.