Cognition-Based Medicine

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By: Helmut Kiene, M.D.

In his recently published book Complementary Methodology in Clinical Research (Komplementaere Methodenlehre der Klinischen Forschung), the German physician Helmut Kiene subjects the prevailing body of scientific data to harsh criticism. He demands that current "evidence-based medicine" be extended to include "cognition-based medicine" which latter gives back to the physician the ability of individual judgment.

Dr. Kiene was recently interviewed by BlickPunkte #2, May 2001, a German alternative health publication. We would like to share the five questions asked him, as well as his answers.

BP: Conventional medicine would like to give the impression that its methods are all scientifically proven and safe. Is this correct?

HK: In all probability only 10-20% of all conventional therapeutic measures are proven safe and effective.

BP: "Evidence-based medicine" appears to be the standard for science. In your book you call it `dogma' and claim it precludes individual medical judgment. What does this mean?

HK: Evidence-based medicine is the current well-established and well-recognized attempt to put scientific research materials in the place of mere authority. Sadly, its limitations in terms of methodology and results are often not apparent. We overlook that a lack of proof of efficacy is not the same as proof of lack of efficacy. Likewise, the unequal value of positive and negative results of randomized clinical studies is not considered. A positive
result is a proof of efficacy, but a negative result (zero result) is not proof of  ineffectiveness. Finally, the dogma that causality (efficacy of a therapy) can principally not be tested on a single patient (except in so-called N=1 randomized trials) is definitively faulty. Because of such weaknesses, evidence-based medicine today can only be of limited value as an instrument serving the health field.
BP: You contrast evidence-based medicine with cognition-based medicine, speaking of complementary methodology. Is cognition-based medicine applicable for conventional methods?
Cognition-based medicine is effective for both. In complementary methodology, criteria for proof of efficacy are analyzed and viewed based on the individual patient. In daily practice every physician uses a broad spectrum of such criteria, whether consciously or unconsciously. The task of complementary methodology is to make these criteria conscious and professional, for future clinical research, as well as in daily therapeutic

applications. Cognition-based medicine as a system of clinical research stands on three pillars: proof of efficacy in the individual case, ongoing studies of efficacy based on many patients over time, and an evaluation of the therapy's value in its historical (literature) setting.

BP: Is the controversy of cognition-based versus evidence-based medicine mainly theoretical or does it have practical consequences, for example in health regulation?

HK: Without theory there can be no scientific practice. Clinical research based on the fundamental principals of cognition-based medicine must be developed. We have already begun this in our research institute. Early results are promising, practical, and future oriented.

The additional benefit is in the physicians' experience. Conventional philosophy has it that medical experience is gained according to the same principles as those underlying randomized studies: the doctor must observe many cases and only then arrive at a judgment of efficacy. Not so for complementary methodology where experience is formed out of individual observation of efficacy.

This leads us to understand why the experience of an educated, reflective physician may be valued higher than the statistical results of clinical studies. Individual medical experience is not something qualitatively worse than clinical studies; it is simply based on other principles of obtaining data. The results of medical experience must be given recognition in health policy decisions.

When physicians learn to rely on their observation and judgment of efficacy, not just by rote, but out of inner activity, cognition-based medicine will become an important instrument providing them with quality assurance in their own work.

Helmut Kiene, MD, author and researcher, lives and works in Freiburg, Germany. Together with his wife, Gunver Kienle, MD, he heads the Institut fuer Angewandte Erkenntnistheorie (Institute for Applied Cognition Theory). His book Cognition-Based Medicine recently appeared, published by the Springer Publishing Co

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