Journal of IiME Volume 2 Issue 2 www.investinme.org P Plluuss ççaa cchhaannggee,, pplluuss cc’’eess tt llaa mmêêmmee cchhoossee ( (ccoonn tt ii nnuueedd )) concept of “force dynamics” by describing the many words and phrases found in naïve speech used to describe various types of causal relation which have presumably been observed directly in the “common-sense” world. Perhaps the clinicians have been using common sense methods to directly observe the causality lying beneath to explain their patients’ symptoms, such as the direct perception of causality and force when the foot contacts a rock- did the foot kick the stone or the stone hit the foot? Samuel Johnson did not have to wait for RCTs to make his decision about the reality concerning forces and hard objects which are put into play when one kicks a rock, since he knew about intentional action. This common sense direct perception of cause and effect has the advantage of being applicable to the individual person in action, not indirectly inferred from a general group of Samuel Johnsons. The former anecdotal evidence is nonconfirmable from a scientific point of view, and thus to be scorned in some quarters, but essential to the clinician who deals with individual patients. It provides the essential contextual background from which an individual patient’s symptom dynamical pattern arises to decide on what kind of cause and what is its cause, what are the effects and their severity, and whether and how these in turn become causes. Thus one can indirectly through dialogue, and directly, through examination and past experience, characterize the causal forces that lie beneath any symptom cluster, and thus become realists. Clinical admonition;- Listen to your patient. He/she is telling you the diagnosis ( ?Osler see ref 26) This ancient but ongoing clinical struggle involves 2 complementary strategies- 1/ Observing patients as individuals using dynamical, prognostic strategies to obtain reliable local knowledge directly in the local context of here and now (deictic) Invest in ME (Charity Nr. 1114035) coordinates, which are thus changing all the time, and 2/ Obtaining general and (mostly) unchanging knowledge based on invariant laws of nature, using universal unchanging coordinates (apodeictic) to make a static model with decisions based on the group results. These results are assumed to be applicable to the individual patient ( as long as he/she is not an “outlier”). The verdict of history seems to be that the Hippocratic approach has been more viable despite periodic attempts to re-instate a Cnidian approach to clinical medicine by focusing on surface symptoms and delaying or neglecting the search for underlying causes ( for recent efforts besides those of NICE see DSM strategy towards psychiatric illness, which deals with symptom clusters and not with underlying causes(13). A similar nominalist approach is seen when research definitions are used to block research instead of facilitating it, holding on to cause-deferring research definitions well beyond their time. This subverts the proper function of clinical definitions which is to facilitate the identification of underlying general and particular causes in individual patients. Properly used, the general confirmed knowledge that is obtained from science is immensely helpful, but only when it is used as an aid in making adequate clinical judgments, instead of as a substitute for this local individual anecdotal clinical knowledge. Together general scientific knowledge and local clinical knowledge complement each other if used skillfully to cover each other’s deficiencies. The Canadian definition of ME/CFS (14) considers cognitive fatigue to be a member of the “neurological/cognitive” component, necessary to the case definition. It makes a huge difference whether one regards fatigue as a decontextualized, separated entity (see 17) to be included as one member of the numerical cluster of symptoms constituting an acausal syndrome (any interactive causal (continued on page 23) Page 22/74
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