TRANSLATIONAL MEDICINE AT THE INTERSECTION OF EVIDENCE-BASED MEDICINE AND NARRATIVE MEDICINE

The content of this editorial is based on the keynote speech I delivered at the Sixth International Congress on Health Issues in Childhood and Adolescence (http://congressocisca.com.br/) held at the School of Public Health, University of Sao Paulo, Brazil, on May 2015. On that occasion, I told two parallel stories to the audience. First, I talked about the many, sometimes-misguided decisions that made me into the professional researcher in the field of Translational Medicine that I am today. Second, I described some of the historical landmarks that led to the development of the field of Evidence Based Medicine, and the consequences of this development for the current teaching and practice of medicine. I received my medical degree from the State University of Rio de Janeiro (Universidade Estadual de Rio de Janeiro – UERJ) in 1986. When I enrolled at the School of Medicine at UERJ, I was naive enough not to know that that specific Medical School represented one of the last bastions of “traditional medicine” in Brazil, which is now known as Experience-based Medicine. For example, teaching at the State University of Rio de Janeiro was still based on traditional medical disciplines (i.e., anatomy, physiology, pharmacology, pathology, etc.), compared with the more contemporary medical curriculum at the Federal University of Rio de Janeiro (Universidade Federal do Rio de Janeiro – UFRJ), which was based on systems. Although considered outdated now, the traditional approach used by my old medical school produced an infernal repetition of the same issues from semester to semester, but it also guaranteed that the information ultimately made an indelible mark in the brain of the poor student. In addition, the curriculum of UERJ was completely rigid, and did not allow the student to “stray” into non-medical disciplines. In contrast, the UFRJ allowed the student who had interests other than medicine to take classes in subjects other than those offered by the medical curriculum. Such rigidity at my medical school was also a torture for me, given that I was a student who had come from a federal technical school (CEFET-RJ) and, since day one, had the dream of becoming a physician-scientist. UERJ was also Brazil’s most traditional of Brazil’s traditional medical schools in other ways. For example, most of the third year of medical school at UERJ was dedicated to medical propaedeutics (or propedeutics), and we spent most of the day in medical wards of various specialties, learning to collect medical histories and doing physical exams. Initially, this was also a nightmare for me. Nevertheless, exactly because I had no other options, little by little, I became more and more comfortable at interacting with patients, and skillful in recognizing signs and symptoms of various diseases and disorders that can affect human beings, which are skills that serve me well until this day. During my clinical rotations, I had excellent mentors, such as Drs. Jose Augusto Fernandes Quadra, Fernando Bevilacqua, Jayme Landmann and Pedro Sampaio. All these individuals had in common an immense amount of knowledge, tremendous passion for the art of medicine, and egos commensurate with these attributes. They rarely allowed the student or resident to question their clinical assessments, regardless of whether such opinions were based on scientific evidence or not (except, perhaps, Dr. Quadra; but that man was never wrong anyway...). “Clinical knowledge is king!” This is what they used to say. In 1987, I was ecstatic because I thought I had finally abandoned medicine after six torturous years of medical school. I had been accepted into the graduate program at the Institute of Biophysics Carlos Chagas Filho at UFRJ (IBCCF-UFRJ), where I would devote myself completely to the practice of basic science. Despite having taken classes with luminary figures such as Professor Aristides Leao and the late Professor Carlos Chagas Filho himself, I noticed immediately a huge difference in the approach to teaching at the IBCCFUFRJ compared with my experience in medical school. In this new environment, the student had been always encouraged to question everything that was being said. Information was always presented as potentially falsifiable; which is typical of the scientific attitude. After a year and a half taking classes and learning laboratory techniques as a graduate student at IBCCFUFRJ, I spent two and a half years on a research fellowship at the Department of Pharmacology in the University of Maryland. This was followed by my return to the IBCCF in 1991 to defend my doctoral thesis in Biological Sciences (Biophysics). From there, I went to Baylor College of Medicine, in Texas, where I did four and a half years of postdoctoral training in Neuroscience. In 1992, the article “Evidence-based medicine. A new approach to teaching the practice of medicine” was published in the Journal of the American Medical Association, JAMA1. After some pushback from leading practitioners of Experience-based Medicine, this emerging field underwent rapid ascension among the medical establishment. Below are some comments extracted from the editorial published in the British Journal of Medicine in 1996 by Sackett et al.2, which addresses some of the initial criticism directed against the original article: • “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the