Lessons from medical history
What was identified by scanners as a brain tumour in 1970 was referred to 250 years earlier as ‘the influence of evil spirits’. And before these advanced imaging techniques were widely embraced by medical specialists, a great deal of water flowed through the Meuse. As is actually the case with any new technology. During his career, Prof. Eddy Houwaart studied recent medical history from, let us say, the last two centuries. “Scientific discoveries do not become ‘true’ because they are true. They have to go through a social and cultural process first.” He discusses the fascinating medical history and its importance for the doctors of the future.
Eddy Houwaart came to the interview despite his severe cold. And no, it’s not a sourvenir from a wild party after his farewell speech a few days prior. Later in the conversation, when talking about the projects he is still going to do now that he is officially ‘emeritus’, he says, “In Italy, I had already received two courses of antibiotics for what I have now. In the Netherlands, we are very cautious with them. And the resistance to antibiotics varies a lot from country to country.” In the coming years, he will explore the backgrounds behind this in greater depth. Just like the rise of the ‘health economist’ in the 1970s. “Very interesting! Defining healthcare economically was a very strange idea. Healthcare consisted of a patchwork of rules and was not seen as an economically coherent whole. Until it suddenly became a problem in the 1970s because we didn’t know how big and how expensive it actually is and how it relates to what we earn in the Netherlands. Now that’s a matter of course, but we’re going to research how this came about and whether things could have gone differently.”
Cataract couchers and the political influence on science
Medical history is a treasure trove of fascinating subjects. Take the profession of ‘cataract coucher’ in the Middle Ages. They knew how to use an instrument similar to an apple corer to remove the lens from the eye without causing further damage (and without anaesthesia). And, Houwaart has also taught his students, they were not all quacks. “Some of them were highly skilled. I tell students this to let them know that before doctors were common, the medical profession was performed by a lot of different professional groups.”
He thought he would become a general practitioner himself; he studied Medicine in Groningen. He followed Philosophy as a minor, through which he also discovered philosophy of science. “You learned to look critically at theories and at what facts actually are. A publication by the German philosopher Gernot Böhme was a turning point for me.” The article described how young doctors in Germany in 1848 went to the barricades for a democratic Germany and the scientific socio-medical approach to endemic diseases. And it described how, due to political circumstances, this did not happen. “The fact that political factors can determine the direction in which science develops was unbelievable to me. That’s what I wanted to research for the Netherlands.” And that is how it all started.
How knowledge is validated in negotiations
His dissertation in 1991 was about the ‘hygienists’, about how medical practitioners in the Netherlands have tried, on the basis of their expertise, to improve public health from the 19th century onwards. Since then, his research has focused on various ‘recent’ developments in medical history, inspired by social scientists such as Mary Douglas. “She had developed methods to show that the continuation of medical knowledge depends on the social and historical context, and that there is constant negotiation between groups and individuals as to what that knowledge represents.”
A concrete example: in the 1950s and 1960s, gynaecologists and neurologists in particular were very interested in imaging techniques that could provide images of the soft tissues inside the body. Ultrasound was introduced, but it was not as easy as 1-2-3. “When X-ray technology was invented in 1895, it took 30 years for doctors to fully understand what they saw and what they could do with it. Those same radiologists thought the rise of ultrasound in the 1950s was utter nonsense. Every technological advancement creates expectations for certain people, but there are also people who don’t see the value in it. The added value has to be determined and that is a social process.” In midwifery, too, it took doctors, together with technicians and patients, 15 years to determine exactly what they saw. The image didn’t immediately speak for itself. What is relevant? “During my education, in the 1970s, there had been a lot of hype surrounding the ultrasound. And then you saw that it also had meaning for future parents, because the unborn baby was suddenly no longer an unknown.” (text continues below image)
The appeal of new technologies to doctors
This illustrates perfectly what has fascinated him so much in his scientific career. “The introduction and development of medical technologies is a very complex social and cultural process, with all kinds of factors that determine whether something is successful or not. That’s what I wanted to show.” As with social history, medical history repeats itself over and over again. “Relatively recently, the Da Vinci robot was introduced, particularly for prostate surgery. It was purchased by a number of hospitals before its added value was really clear. Was it safer, more efficient? We didn’t know, and yet the device was introduced—because the expectations were there. Sometimes they come true, often they don’t.”
Houwaart saw countless technologies being dismissed or repurposed. Diathermy, the stimulation of heat generation within muscles, was once expected to cure acne or even cancer. “Eventually it ended up in physiotherapy, where it turned out to be useful.” He also saw how new technologies can cause an explosion of treatments. Take the heart valve surgeries that emerged in the 1950s. “Then the heart could be stopped with the heart-lung machine and, especially in the US, the number of cardiac valve operations increased explosively. It later turned out that a large proportion of these patients had thrombosis, resulting in a stroke. However, because they didn’t return to the cardiologist, but went to the neurologist, the complication went unnoticed for a long time. It was not until the 1980s that it was rightly concluded that these people should be followed-up on neurologically as well as psychologically after the operation.”
Medicine is an art, not an exact science
His research led Houwaart to the conclusion that medicine is not a natural science, such as chemistry. “Medicine is a ‘Handlungswissenschaft’ [or practical science]. As a doctor you look for the best treatment and sometimes you can prescribe antibiotics as well as a homeopathic remedy. Why not, if it helps the patient? Historically, there is a permanent tension between scientific knowledge and the medical practitioner who sits in the consultation room with that one patient.”
But what about the introduction of protocols that attempt to lock down healthcare into standard treatment methods nowadays? “Based on the past, I think it’s an illusion that good medical practice can be reduced into a cookbook. That’s never going to work.” Houwaart sees setting up protocols as a kind of scientific basis for practice, which is certainly useful, but which does not do justice to the ‘gut feeing that every doctor must also have. “And it’s also a consequence of the efficiency thinking that emerged in healthcare in the 1980s and 1990s. So there are two sides to it.”
Why medical history is important for doctors of the future
Although he thinks medical history, like ethics and philosophy, should be an integral part of the Medicine programme, this is often not the case. “I think these are important subjects to teach students how to navigate in an increasingly complex world. But I have no illusions. A quarter think it’s interesting; a quarter don’t like it at all; and half are neutral about it. But that goes for more subjects.”
That does not detract from his view that medical education is not just vocational training. “It is an academic programme in which you teach students to think critically about themselves, their future profession and the knowledge they apply. But also—knowledge changes. During my studies, it was still said that an ulcer was the result of all kinds of stress factors. In the 1980s, this turned out to be nonsense; a bacterium was the cause. And so our answer to the question of ‘What is Alzheimer’s disease?’ is different today than it will be in twenty years’ time. It was one of the most important lessons from the philosophy of science for him—scientific discoveries and even statistics are not true because they are true; they are made to be true, through a social process. “Of course, physical abnormalities are undeniable realities. But a brain tumor in 1700 is something completely different than in 1970.”
The Interfacultair Medisch Studentenoverleg (IMS), the largest Dutch representation organisation of medical students focused on medical education, will hold its 2019 IMS congress about the future of medical education in Maastricht on 19 and 20 October. Prof. Eddy Houwaart has been asked to give the keynote address.
About professor Houwaart
Prof. Eddy Houwaart officially said goodbye as Professor of Medical History at Maastricht University on 12 September, with his speech ‘Nothing is as informative as medical history’. For the time being, he will continue to teach and conduct research into antibiotic resistance in Europe and the rise of the health economy in the Netherlands in the 1970s.