Dear listeners! Warning: this course contains shocking materials and is not recommended for viewing to persons with weak psyche, minors and pregnant women. The course describes subject and methods of Pathophysiology, its place within system of biomedical sciences and history. It includes General Nosology (concept of health and disease, general etiology and pathogenesis, pathological processes and states, role of causal factors, conditions, reactivity and somatotype in pathology). It gives systematic of locally and centrally driven typical pathological processes: arterial, venous and combined hyperemiae, stasis, inflammation, immunopathological processes (including allergy and autoimmune disorders) acute phase response, fever, stress, shock, etc. Course deals with functional, metabolic and informational aspects of typical pathologic processes, like disorders of signaling, reception, post – receptor translation, programming and program archiving, conflicts of programs in living systems. It contains the consequent analysis of the injury and defensive responses as regards separate cells, organs and tissues and the whole organism. The lectures based on author’s original three-volumed textbook and workshop in Pathophysiology republished in Russia many times.
1_ 6 "Scientific Reasoning vs Clinical Reasoning"
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From the course by Saint Petersburg State University
General Pathophysiology
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From the lesson
Pathophysiology as a Science
Meet the Instructors
Churilov Leonid PavlovichAssociate Professor, Full Member of International Academy of Sciences (Health and Ecology)
Department of Pathology, Faculty of Medicine
Medicine is based on natural science,
but medicine is not only natural science.
It has many other elements.
This part of my lecture is about the equation and about the bridging
between scientific reasoning of a scholar
and clinical reasoning of medical doctor.
Of course every professional must be able to think.
But you know professionalism of
experimental scientist and professionalism of medical doctor,
they are a little bit different and they require for different competencies,
and even the rules and styles of reasoning are different.
Medical professional reasoning and scientific reasoning of experimental scholar,
they are not identical.
Otherwise, biomedical scholars could treat patients but
even if you are a world famous academician in physics or chemistry,
government will not give you a right to treat
patients in hospital or in outpatient department.
For that you need MD diploma.
You may be very skillful in biology,
in chemistry, in physics,
and still without MD diploma.
And do you know the main difference between
medical faculties and all other faculties of University?
Medical faculty is single one where people study pathology and pathophysiology.
That's why I believe that pathophysiology is a bridge
between scientific reasoning which is allowed in junior courses of medical school,
and clinical reasoning which will come to you in senior courses of medical education.
Look at these pictures.
You can see kind medical doctor and you can see crazy experimental scholar,
wild, absolutely concentrated on the scientific truth,
by any costs and any means from Hollywood movie.
Do you really think that one can substitute another?
They are too different.
But medical student must acquire something from
experimental scholar and something from kind medical doctor, and combine it.
Pathophysiology will help you to combine that.
Now doctors, I would like to discuss with you
the main differences between medical professional reasoning and scientific reasoning.
In medicine, you always try to minimize the risk of mistake.
And you know that Latin proverb of medical doctors "Noli nocere".
First of all, do not cause a harm to your patient.
But you know in experimental science,
the situation is quite different.
A scholar is bad scientist if he does not mistake.
He is obliged to do intentional mistakes.
If a scientist is afraid to be wrong,
it is bad scientist.
The chain of intentional tests and mistakes, in fact,
is normal course of any experimental project in the natural science.
In clinical medicine and in experimental science,
we have different values,
the supreme value for medical doctor is the benefit of patient.
Patient's benefit is prior to everything and even prior to the truth.
Because you know investigation of living body is limited.
It is limited with the necessity to spare patient and to protect his/her interests.
Another situation exists in experimental science.
The truth is supreme value in experimental science.
Sometimes it is truth by any means and if you are an experimental physicist,
you can even split the atom and atom will stop to exist but you will understand how.
It is constructed, how it was constructed.
In clinical medicine you sometimes can not do that because you cannot
kill your patient in order to understand what is inside.
That's the problem.
Alfred Nobel, experimental chemist,
he noticed it very well when he experimented with nitroglycerin,
that nitroglycerin gives him relief from angina pectoris.
He noticed that nitroglycerin is
able to relieve attacks of stenoca rp i ne.
But he did not invent corona lytic drug, he invented explosive.
That's the difference, either benefit for a patient is first of all,
or the scientific truth is first of all.
And the last significant difference between clinical medicine and experimental science,
is concentrated in the title of the Jack London's novel, "Time doesn't wait".
If you are a clinical doctor dealing with sick patient,
you always are limited in time,
because disease has its own time,
its own clock and if you will not hurry up,
the disease will decide all problems with that person.
You will not save him or her.
You are always limited in time.
You never can expect that you will have enough time
to know all the details about this particular living organism,
probably for that you need several months.
And even if you have the methods,
and even if you have the possibility to make
all necessary analysis including most sophisticated ones,
you simply have no time.
You always must start to act in clinical medicine.
Without complete knowledge of disease,
without complete knowledge of this particularly individual
and without complete knowledge of drug,
and its possible adverse effects.
You never know what you will encounter around the corner in clinical medicine.
In experimental science, you also do not know what is around the corner,
but you have at least enough time.
If you will finish your research project,
your pupils, and pupils of the pupils,
after many decades after many years,
will finish and it will give a result and Nobel Prize.
So in clinical medicine,
your thinking should be very, very emergent.
You'll never have enough time because there is natural cause
of acute disease and absolutely different situation in research,
you will research as long as you need.
Finally, you will get the truth.
So you can see that there is big difference.
But look at this picture,
you can see here, experimental scientist,
famous Russian immunologist, Ilya Mechnikov,
he was not a medical doctor,
but his closest disciple,
Nikolay Christovich, who is sitting by him,
his closest disciple was introduced clinical doctor,
and they were in close collaboration,
in close friendship, and it was Christovich who officially nominated his teacher,
Mechnikov, for a Nobel Prize.
Mechnikov was not a medical doctor,
he was Associate Professor of our university specialist in zoology.
So, the union between medical professional and professional in basic science is possible,
but only if they both pay much attention to pathophysiology.
So, if you know very well the canons and the rules of the scientific reasoning,
you are not yet a doctor.
And even if you can know very well all the rules of
clinical behavior and all the canons of clinical reasoning,
that is not enough to comprehend the disease.
You need to take from here and from there,
you need some bridge between scientific reasoning and clinical reasoning.
Pathophysiology is the bridge between scientific and clinical reasoning.
But, if the medical doctor really needs that,
maybe it's enough to know physics, biology, chemistry,
and have common sense,
common sense in your head,
and you will be a good doctor.
Look at this person.
This is a famous physicist,
cosmologist, Stephen William Hawking.
And he said, "Common sense is just a prejudice
in the spirit of which we are brought up".
So, he was very negative about common sense,
and common sense really is best helper in medicine,
and they will show that to you.
Which doctor would you prefer for yourself: Optimist or pessimist?
As for me, I prefer to have a doctor which always expects
the worst variety and always ready for that worst variety of events in advance.
But those who think about worst possible variety, they are pessimists.
It means pessimistic doctor is always better than optimistic one.
Patient must be optimistic, but doctor, professionally,
is obliged to be ready for the worst,
which means to be professional pessimist.
Pathophysiology in our understanding is part of medical curriculum,
putting a reasonable pessimism into doctor's mind.
But the pessimism is very useful,
and the necessity of this pessimism is clear.
If you will think about incomplete knowledge which doctor has about disease,
about an individual, about a drug,
but responsibility of medical doctor is always complete.
That's the main contradiction of clinical medicine.
And to deal with that contradiction,
you need to know pathophysiology.
In the WHO organization charter,
it is written that pathophysiology together with anatomic pathology,
is a basis of medical intelligence.
Now, doctors look at this picture.
This is a renal glomerulae.
From left side, you can see normal glomerulae.
And you can see that the capsule of this glomerulae is very thin, very slim.
And the cells around glomerulae, both sides,
are also very slim with very, very thin processus.
And on the right side is the same renal glomerulae, but in disease.
The disease is called glomerulonephritis.
And you can see that the cells are thick, they are swollen.
The capsule also became thick,
huge, with some deposits on it.
And their overall fence, overall barrier,
between the blood and the primary urine is very
thin in case of health and very thick and huge in case of disease.
Now, i ask you,
which fence is easier to penetrate through: thin or think one?
If you rely upon common sense,
of course you will answer that: thin fence is easier to penetrate than thick one.
But look on this matter from the point of view of pathophysiology.
In health, there is no protein in urine,
just traces, in disease,
huge amounts of protein may penetrate in urine, in health,
there are few cells in urine, and in disease,
you can see a lot of erythrocytes and leucocytes in the portion of daily urine.
It means that, in fact,
everything goes in opposite,
in contradiction with common sense.
In health and in disease,
the permeability of this fence is different,
but thinker fence, thicker barrier in disease is more permeable.
And you cannot explain that if you are limited with common sense.
You need to know pathophysiological facts,
you need to know about
the repellent effect of negatively charged molecules on the surface of
that fence in order to understand why glomerulae
became more permeable in spite of greater thickness of the capsule.
So, in medicine, you need to rely upon facts and you need to rely upon pathophysiology,
not only upon your common sense.
Now I must say a few words about experiments and bioethics.
And I must say categorically,
experimental phobia is counter indicated for
any medical professional clinical experimentation in the form of
functional and diagnostic tests with patients
and with their cells is a routine element of health care.
You should not think that experiments exist only in the lab.
Look at this person,
he was far from experimental science, he was a preacher,
Elster Nectariy of Optina Pustny Monastery in Russia.
He was also a philosopher,
and he once told the students of Medical Faculty of Kazan University,
"Study in such a way that your scientific approach would not eliminate morality,
and morality would not blemish sciences''.
In that case, you will have complete success of all your science.
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