Difference between a medical doctor and a medical scientist
Almost all the lay public thinks only the medical doctor is the expert
in medicine, especially when they need to see one when they are sick. Almost
none thinks about other health-care professionals such as the medical
scientist, not even the nurse practitioner, dietician, osteopath, naturopath
when they are sick, nor do they think about the medical contributions of these
experts, their expertise, their role, and their support in health care too.
As a clinician and a former medical scientist in research, I sit on the
fence to watch this show that no one sees, perhaps not even some doctors could
see though they often depend heavily on blood tests to come up with a
definitive diagnosis using the results and efforts of these medical scientists.
It is a case of self-importance, arrogance, egoistical attitude,
and a cocky character of any individual from any profession.
If we look at the history of
medicine from this link below, we find that most of the contributions for the
advancement of medicine came not from the doctors who are basically clinicians
performing clinical work in the wards of hospitals, but from scientists, such
as anatomists, physiologists, bacteriologists, physicists, biologists,
geneticists working in their laboratories. They too are experts in their own
specific fields working in their laboratories related to medicine unlike
medical doctors and nurses working in hospitals. Here is the link on their
discoveries and their contributions for the advancement of medicine over the
centuries.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4379645/
How and when did the lay public associate medical experts in health care
only with doctors as clinicians and nurses, leaving out every other
professional who contributed silently without funfair and drum beating.
In a paper published by the Royal Society of Medicine (RSM) in London
where I was admitted as a Fellow in 1994 just before my retirement from the
Institute for Medical Research in Kuala Lumpur, Malaysia, they showed most of
the Nobel Prize winners in Medicine or in Physiology were won not by clinicians
(medical doctors), but by medical scientists. The Nobel Prize without reserve
is the most prestigious award in the world, but RSM was dismayed that there was
hardly any clinician who won a Nobel Prize in Medicine since 1927. They were
all won by medical scientists instead who were all non-clinicians. But we must
ask ourselves how could doctors as clinicians who do not work in a research
laboratory to discover anything new, but merely use the results of research by
other scientists or products of drug manufacturers and merely apply or give
them to patients whether in diagnostics or in treatment. In what way do they
deserve that esteemed Nobel Prize in Medicine or in Physiology?
Here is one of the papers by some disgruntled senior doctors from the
prestigious Royal Society of Medicine in London.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164255/
Allow me now to give a very brief look at the training of a medical
doctor in a medical school. During my time in the 1950’s and even before that,
a student taking up a 5-year medical course hardly studied any scientific
subject in the first 2 pre-clinical years. All they studied was anatomy and
physiology, not even normal biochemistry so crucial in the understanding of the
chemistry of the body that turned pathological in disease. Neither do they
understand how the normal functions of a body in physiology turned abnormal as
in pathophysiology which is a study of disordered, or abnormal
physiological processes associated with disease or an injury. A medical student
should not learn only anatomy and physiology in their preclinical first two
years, leaving out all other medical sciences such as cellular and molecular
biology, biochemistry, pharmacology, microbiology, parasitology, epidemiology,
etc, etc, but he must also be able to understand and translate why the normal
functions of the body become disordered in disease. But this was not done or
taught to them. In their remaining 3 clinical training they were straight away
taught features of the disease, how to diagnose to differentiate one from the
other, and how to manage or treat them mainly through the use of drugs and
synthetic pharmaceutical products. How do we expect them to win any Nobel Prize
in Medicine or in Physiology with this routine training?
But the science of disease and
medicine were not yet very advanced some 100 years ago, so a student learn just
anatomy and physiology in their 2 preclinical years before starting their 3rd,
4th and final 5th years to cover a wide range of clinical
subjects from basic anaesthesiology, emergency medicine, otorhinolaryngology
(ear nose throat), general medicine, general surgery all the way down to
ophthalmology, paediatrics, tracheotomy. Each of these disciplines were taught
in the wards or given just a few lectures on each. By the time the student
graduates as a doctor, he becomes a generalist, a jack of all trades, master of
none unless he specializes in one of the disciplines of medicine or surgery
after working for some years as a medical officer.
In one way he is better than a
medical scientist who does not undergo such a broad-spectrum training in all
the disciplines of biomedical sciences, but he concentrates on one of the
dozens of biomedical sciences such as biochemistry, bacteriology and
microbiology, entomology, cellular biology, genetics, all the way down to
parasitology to zoonotic diseases. He becomes a scientific specialist without
knowing much about the other biosimilar medical sciences. He is no longer a
generalist like a newly minted medical doctor.
The problem with doctors not being
able to specialize is because it will take him at least 3 years after his
horsemanship working in a specialized department of a hospital and another 4
years in a university before he can specialize in a particular field of
medicine or surgery.
However, as the years went by, more
and more discoveries are made in bacteriology, mycology, parasitology,
virology, genetics, cellular and molecular biology, immunology, neuroscience,
physiology and other medical sciences that a student studying medicine these
days also need to learn a little bit on some of these subjects such as
histology (the study of tissues) as part of anatomy, rather than just on the
gross structures of the human body (anatomy) on muscles, bones and nerve
supply. They also need to learn a bit on biochemistry so that they can also
understand abnormal biochemistry and how drugs work, their pathways as in
pharmacology. They would be able to interpret the results of blood, urine and
serological tests and not just look at their normal, low or high levels.
Some haematology is also introduced
in the current medical syllabus so that a student-doctor have some idea on
blood count and what happens in an infection or on blood groups if a blood
transfusion is needed.
But what they learn depends very
much on what the university or medical school offers. I cannot speak for all
the universities that teach there as this varies considerably from medical
school to medical school even in the same country, let alone from different
countries. Hence their degree recognition on graduation depends on place to
place they graduated.
After the student leaves the
preclinical subjects, they go into their clinical years where by then the
student would have gathered some ideas, though hazy ones, how they fit into
what they actually see by the bedside of the patient. Their exposure by then
would be more clinical application rather than academic as in medical sciences.
Some 200 years ago before
scientists made discoveries in biochemistry and cell biology, energy and
metabolism, pharmacology, genetics, pathology and immunology, epidemiology,
neuroscience, on bones, muscles and skin, endocrine and reproductive systems, the
cardiovascular system, haematology, the respiratory system, the renal system,
the alimentary system, diet and nutrition, genetics, molecular biology and
DNA…etc, doctors then have not much clue why and how the body falls sick. They
don’t use blood tests, laboratory investigations, imaging or any of these
objective investigations where measurements are made. They depended mostly on
what patients told them from symptoms they felt, and the signs they saw,
besides history of their illness and physical (clinical) examinations they
conducted. Theirs were more subjective rather than objective using measurements
and data. Today, the practice of modern medicine is a combination of
something subjective and clinical, and objective through lab measurements by
the medical scientists.
Over the short one or two centuries
tremendous progress was made by medical scientists, but not by medical doctors
into why and how disease happens through investigations in their laboratories
or in field studies, and the medical knowledge gained, passed on to the medical
doctors to be applied on the bedside (hospital bedside of patients).
In short, research findings that
plough into new frontiers of medicine are passed on by the medical scientists
to the practising medical doctors. In recent years, we call this as
“translational medicine”, meaning “translating” research findings from the
bench of a scientist to the beside of a patient (bench to bedside) to
improve diagnostic methods and treatment for better therapeutic outcome
and prognosis.
But all these medical advances and
contributions are made by the medical scientists who deservingly receive all
those highly esteemed Nobel Prizes in Medicine or in Physiology leaving the
clinicians receiving hardly anything so celebrated and prestigious.
But for the ordinary public and lay
people who have no clue what was going on behind the medical scene, they
glorify the medical doctor rather than the medical scientist. In truth almost
99.5% of the medical discoveries in prevention, diagnostic, treatment are
worked out behind the screen by medical scientists rather than by the clinician
who are more involved in using all these discoveries, and drugs available and
given to them by scientists on how to use them. They worked for 10 to 15 years in
pharmaceutical laboratories to develop these drugs that underwent so many
stages of research and development before the doctors were allowed to use them.
The ordinary patient did not see this, nor are they aware. They only see
the doctor face-to-face during their visits, consultations and treatment. Thus,
they give all credit only to their doctors whom they see face-to-face. They did
not see the others behind the screen.
The patient doesn't even give any
credit to the anaesthesiologist, the radiologist, the haematologist,
histopathologist, immunologist, geneticist who are actually specialist doctors,
not medical scientists whom they never saw to whom their doctors refer and
consult for their greater expertise. Because they never saw them working
silently and without drum beating in their diagnostic labs, they seldom get any
glory from the patient even though they were specialist doctors. If they are
not even aware of specialist doctors like the radiologists, histopathologists,
immunologists, medical microbiologists behind the scene to whom their
doctors send specimens for HPE (histopathological examinations from biopsies),
or consult their higher colleagues, how do we expect them to pay respects
to non-clinical scientists who work in pharmaceutical chemistry, pharmacology,
toxicology, drug synthesis for newer and better drugs, their evaluation, usage
and indication and dosage…etc, etc. None of this work is done or contributed or
performed by the medical doctor whose job is only to use these drugs, medical devices,
and diagnostic tools developed by medical scientists and given to them on how
to use them. The doctor has no clue how to develop them. Their job is only to
give or prescribe them to the patient whom they see directly during the
consultation. The patient never saw the rest or consulted them for their
expertise. Thus, they may have the impression it was the doctor who did all the
job, from lab diagnosis to the development of the drugs they were prescribed.
Suppose all the lab support given
by the lab scientists and lab technologists, and all the imaging devices and
electronic devices developed by the medical engineers through R & D
including drugs developed and given to doctors were withdrawn from the medical
doctors, all the clinicians will be instantly ‘paralyzed’ and completely
helpless. What are they going to do then? All they can do is take medical
history, do some clinical examinations like physicians 200 years ago using
their eyes to see, fingers to palpate and percuss, and listen to heart, lungs
and body sounds called “auscultation”. There is nothing else they can do. There
will be no imaging with machines developed by electronic and mechanical
engineers, all those tens of hundreds of blood, serological and urine
examinations done and developed by biochemists, or drug developed by
pharmaceutical chemists, and studied by the pharmacologists and toxicologists,
etc, etc all the way down attributed to the medical scientists and medical
engineers, but used by the medical doctors.
The clinician at most can offer
is, to prescribe some herbal, botanical medicines or some natural
medicines on which they have no clue, completely absent in their based-based
training in allopathic medicine. Their practice would be guessing from hearsay
from others. There will be no lab data and objective measurements to support,
and everything from diagnosis to treatment would be subjective and not
objective since the only objective and definitive diagnosis and treatment can
be offered is through measurements developed by the unsung scientists or even
by their medical specialist counterparts helping the frontline doctor behind
the scenes. Most of the public does not know this. They think it was the doctor
who knew and offered these services, leaving better and more qualified experts
behind the screen.
But I admit it is entirely not
true. I know of even specialist doctors who consulted and referred their
patients to medical scientists who are more specialized than them. For example,
I know of a very famous professor of medicine who referred a couple to a
non-medical geneticist in the same university for advice. The couple intended
to get married but both of them suffered from G6PD
(glucose-6-phosphate dehydrogenase) deficiency or was it beta thalassemia
major I can’t remember. They wanted to know the chances of their child getting
the disease passed on. So, their physician referred them to see the
non-medical geneticist for more expertise advice. So, it should be a teamwork
effort between the clinician and the medical scientist for the sake of the
patient. The medical doctor who is basically a clinician should not take all
the credit for himself and leave his supporting colleagues or counterparts
aside in health care for the sake of his patient. I don’t think this is ethical
practice. Both the academic scientist and the practising doctor should work and
consult each other for their respective expertise, but the final clinical
decision should be left only to the medical doctor.
Likewise, researchers conducting
clinical trials must have at least a clinician on board to evaluate the
clinical aspect of the study.
I remember a very highly qualified
cardiothoracic surgeon at Gleneagles Hospital in Kuala Lumpur who worked
together in the same hospital with my youngest brother who is also a
senior consultant cardiothoracic surgeon and professor in surgery at the
University Hospital, University of Malaya. He told me of a team of researchers
from the Malaysian Palm Oil Board who wanted to publish a paper on a clinical
trial done on palm oil without any clinician in the team. This heart surgeon
was a member of the medical ethic committee who vets medical research done in
Malaysia. He was also a member of the editorial board of a medical journal. He
told me about a clinical trial from the Malaysian Palm Oil Board that was
conducted by only scientists without a clinician inside. I was taken aback. How
could this be, a clinical trial being conducted by non-medical scientists
without a clinician in the team.
I firmly told him he should not
approve this, or have their papers published in the journal. It is
unimaginable for me for a clinical trial conducted without the presence of a
clinician as part of the team. But if it was purely a lab study without any
clinical examination or clinical evaluation involved, then it is perfectly okay
to have only scientists in the team, but never in clinical trials. I firmly
supported his complaint.
In fact, in most clinical trials,
they even have at least two clinicians to evaluate the efficacy of a new
treatment, the first physician who designed the study, and the second who
evaluate the results of a treatment separately so that it is unbiased. Often to
make things harder and more scientifically acceptable, the first doctor who
gave, say, a new drug against a placebo does not even know which is the real
drug and which is the placebo. Neither the patient knew. This we call it
‘single-blind’ and if a second physician calls in to do the evaluation, and he
too does not know which is the real drug and the other the placebo given as the
control group or otherwise, this we call it ‘a doble-blind’ study. In
statistics we try to avoid bias should all the parties know what they were
given. Of course, the other members of the research team not involved in the
clinical evaluation know the real drug and the placebo.
In my own experience leading a team
of doctors and scientists in clinical trials, I don’t even know the expertise
and knowledge of my other colleagues who tried to explain during our countless
technical meetings before the study began. I respect their expertise and
decision how to go about solving a difficult problem that may interfere with a
study. We respect each other and not show our arrogance that we know
everything. Everything in medical research is new. We need to think and plan
out of the box. Our textbook knowledge was only a small platform serving as a
springboard to jump into a new and unknown platform for medical discoveries.
Of course, not all medical
discoveries are translated straight away into medical practice. Old standard
ways from textbooks die hard and they change only very slowly much to our
disappointment because research for new diagnosis and treatment doesn't come
cheap and overnight. The practice of translational medicine is very slow. They
need numerous clinical trials in stages like new drugs undergoing 3 to 4 stages
of trials before marketing, and even then, there is post-marketing
pharmacovigilance.
Clinicians are firmly brainwashed
by the very financially powerful pharmaceutical industries to use their highly
costly patented drugs for generations despite new alternative therapeutic
approaches and better therapeutic outcomes. In translational medicine, there is
not much medical researchers can do to change the mind-set of older generation
clinicians. Even to change from the bench to the bedside as in translation
medicine it takes a long time for approval from the Ministry of Health and
other ethical and regulatory bodies.
What I write here is only a very
brief run through the application of medical sciences into medical practice not
seen by the public and ordinary patients who think health care is only
contributed by doctors and nurses as they see in TV and drama movies. All they
see in drama movies and even in hospitals are all those ‘fantastic’ medical
machines and bleeping electronic equipment with doctors in white coats and a
stethoscope around their necks. They have never thought doctors don’t invent or
produce all these medical gadgets or drugs. They depend completely and totally
on other medical scientists and medical engineers to invent and produce them
and teach the doctors how to use them. These the patient and the lay public
never saw.
Without the rest of their
scientific and engineering counterparts all the doctors could do is to take a
medical history and write tons of notes on the same thing, percuss, palpate and
auscultate with a stethoscope for murmurs, bruits, crepitations, rhonchi, bowel
and other body sounds. There will also be no drugs or medicines because these
are researched and produced by specialists’ medical scientists working silently
in Big Pahrma laboratories. There will also be no lab or blood tests as these
are produced by biochemists and other biomedical scientists working in research
laboratories. There will be no surgery, because even surgery requires drugs,
and surgical instruments and monitoring machines researched and produced by
pharmaceutical scientists and medical engineers.
Maybe the best the doctor can offer
is some dietary or nutritional advice for which he is also not qualified as
these areas are the expertise of a dietician and a nutritionist. Maybe some
herbal or natural medicines from the plants for which he is also not qualified
as his system of medicine is allopathic and drug based. Maybe offer some
bone manipulation. That also he is not qualified as this system of medicine
belongs to the osteopathic and chiropractic doctors.
We shall in the next article write
on the professional role of a nutritionist or dietician vs. the role of a
nutrition scientist like we do here on a medical doctor vs the role of a
medical scientist.
Both the doctor, the nutritionist
or a dietician are all licensed professionals whose professional titles are
protected by law compared to a medical scientist or a nutritional scientist
whose training is more academic than applied. The title “nutritionist” is
licensed and protected in most countries these days unlike 30 years ago when
anyone selling some food supplements could call themselves a “nutritionist”
without any license and call themselves a “nutritionist” after a two weeks
“training” in a hotel.
We shall discuss all these issues
and problems, their roles and scientific contributions later for the
advancement of nutrition and their practices in health care and disease
prevention, as well their therapeutic values in disease. They too have their
professional problems dealing with the ignorant public.
But give me rest first. I highly value your inputs and comments in the comment column below this article
Thank you for your time and reading.
Lim jb
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