ââåstudies in Medicine Its Art History Science and Philosophyã¢ââ
access_time published fifteen.08.2019
Has medicine become a science?
Stance
Has medicine become a scientific discipline?
fifteen.08.2019
In the nineteenth century, Western medicine was still a prescientific art. Then William Osler gave the bones sciences of medicine a central role in his epoch-making textbook of medicine and brought them to eminence in medical educational activity, and inquiry in those sciences had its commencement major impact on medicine. Those dramatic, scientific discipline-based advancements in medicine led to the formulation of modern medicine as a science. But in medical academia today there is a major divergence of views almost this. We argue that medicine still is, and always will be, purely an art, with medical research extrinsic to information technology. Nosotros delineate the implications of the recognition of this for medical academia.
Hippocratic medicine equally a prescientific art
In the Hippocratic conception of medicine, it was an art. Thus, the most widely known of the Hippocratic aphorisms opens with the words "Life is brusque, the fine art long..." and in the Hippocratic Oath, each freshly-minted physician swore major commitments to his teacher of "this fine art." In this type of usage, our contemporary discussion 'art' denotes the interest of particular cognition and skills in the genuine practice of the art in question. The Hippocratic physician was a practitioner of 'the art of medicine' in this pregnant of 'art.'
This fine art was rooted in a profound innovation in the philosophy of medicine, at a time when 'temple medicine' was dominant in Greece. It grew out of emancipation from belief in divine healing of illnesses, in which healing was sought from Asclepius himself and/or his daughters (Hygeia and Panacea) in sleep ('incubation') in the inner court of one of the numerous temples of this god of medicine. In a radical departure from this, Hippocratic physicians were philosophically committed to practices based on empirical knowledge rationally derived from experience in the exercise of the art.
But the substantive foundation of this medicine was, ab initio, antithetical to empiricism; information technology was doctrinaire rather than empirical. Sickness was viewed as an overt manifestation of 'imbalance' among the postulated iv 'humours' in a person'southward body (blood, phlegm, yellow bile and blackness bile); and for restoration of that balance, bloodletting was considered a virtual panacea.
Exterior of Greece, an decidedly influential abet of that medicine – its bloodletting included – was Galen, who had been highly educated in philosophy and medicine in the Hellenic world, where a very extensive literature on 'Hippocratic' medicine had developed. Through his extensive writings in Rome in the second century Advertizing, he became the principal authority in European medicine, a status which lasted throughout the Middle Ages and the Renaissance.
Later Galen, Hippocratic bloodletting was famously practiced and propagated by, among others, Thomas Sydenham, the 'British Hippocrates' in the seventeenth century, so, a skilful century afterwards, even more radically and influentially past Benjamin Rush, the then-preeminent dr. in America. Most notable, even so, are the recommendations equally recently equally 1892 of the use of bloodletting (for pneumonia, among others) in the highly-esteemed and for decades very widely-studied textbook of medicine by William Osler [1], in his time the preeminent doc in the earth.
Thus, physicians' experience with bloodletting – over the two millennia of its Hippocratic deployment (post-obit its age-onetime prior use in Egypt) – did not seriously undermine their faith in the doctrines underpinning its apply. And reliance on experience in the practice of medicine as the source of the noesis needed in the practice of medicine too stood the examination of that very long time.
The main bespeak of these historical notes in the present context is that from antiquity all the way to recent modernity, Western medicine was a Hippocratic art – in the Aristotelian sense of the fine art/technê of homo healthcare, distinct from any scientific discipline/epistêmê (the pursuit of abstract knowledge). Hippocratic medicine was, specifically, a prescientific fine art.
Scientific discipline defining mail service-Hippocratic medicine
Hippocrates and Galen are, unquestionably, eminences of the highest gild in the history of Western medicine, and Osler, at to the lowest degree arguably, rounds out the troika of such luminaries.
Thinking and writing virtually postal service-Hippocratic medicine was Osler's sole focus in the first four years of his professorship in the faculty of medicine at the nascent Johns Hopkins University. The result of this major effort was his epoch-making tome The Principles and Practice of Medicine (ca. 1100 pages) [1].
The contents of this landmark text were organised according to a particular taxonomy of illnesses ("diseases"). This taxonomy was a reflection of the fundamental novelty of mail service-Hippocratic medicine: the humoral doctrine about the essence of illness (singular) was supplanted past knowledge about illnesses – nigh the pathology (anomalies of construction and/or role) definitional to a big multitude of illnesses, as established by medical science.
Osler did non ascertain the concepts he associated with the terms in that book'due south title – "medicine" or the "principles" and "practise" of information technology. Nor did he otherwise indicate whether he thought of the practice of the post-Hippocratic medicine which the book addressed equally however beingness a prescientific art or a scientific fine art.
The medical education that Osler introduced at Johns Hopkins was centred on the source of that fundamental novelty in mail-Hippocratic medicine. Thus, the bones sciences of medicine were the sole focus of the first two years of the iv-twelvemonth course of education, which followed the required 'pre-med' studies in physics, chemistry and biology. The other two years were devoted to medicine proper.
This education was lauded and held as exemplary in the highly influential "Flexner report" of 1910 [ii]. In it, Abraham Flexner reported on his review of medical instruction in the US and Canada. This review was instigated past the American Medical Association (AMA) and implemented under the auspices of the Carnegie Foundation for the Advancement of Teaching.
Flexner's judgment of the superiority of the educational activity at Johns Hopkins was fully embraced by the AMA, and this education was consequently adopted as the standard in the US. Other countries gradually followed suit, almost universally. Thus, through his signature textbook and the instruction he introduced, Osler gave scientific discipline an eminent part in medical academia at large, making it Oslerian in its fundamentals. The science with which he was concerned was the aggregate of what we now call the bones sciences of medicine.
Medicine itself becoming seen as science
At the time when Osler was introducing this science-heavy education to medicine, the kickoff major impact of science on the practice of medicine was taking place. It was a two-pronged affect – of scientific discipline from outside of medical academia and also outside of medicine proper. Information technology was not the availability of new noesis for deployment in the practice of medicine. Rather, the novelty was the availability of new products and processes for use in medicine.
There was, for i, the bear upon of the biological research of Louis Pasteur and Robert Koch. Knowledge from this research had become 'basic' to the evolution of highly constructive (and reasonably safe) vaccines for epidemiological use and for preventive medicine of the clinical variety, as well. And for another, chemical research in the then-incipient pharmaceutical industry had provided for the development of therapeutic and palliative medications – 1 of which was aspirin – for use in clinical medicine.
These dramatic advancements in medicine, resulting from medical enquiry, gave rise to common conception of modern medicine as a science. This novel idea substantially enhanced the social status of physicians, particularly in America. (And and so physicians adopted the use of scientists' laboratory coats as a replacement for their prior striving for respectability by the use of frock coats and gold-headed canes.)
This uncritically adopted – and to physicians very fraternal – conception of modern medicine as a science is at present expressed, in a way, even in the most eminent of the dictionaries of medicine. Thus, according to Stedman's [three], medicine is "the art of ... the science concerned with ...", and in Dorland'due south [4] the corresponding definition is "the fine art and scientific discipline of ..." These definitions appear to imply that modernistic medicine is the union of 'medicine the art' and 'medicine the science'.
This duality in the now-mutual conception of the essence of medicine is, however, objectionable on account of its construction. It defies the teaching in unproblematic logic that a logical definition posits the 'specific divergence' of the affair in question as a species of its 'proximate genus' – its singular proximate genus [5]. In logical terms, therefore, medicine can be defined as a species of an fine art, or of a science, just not both – specifically, as a species of the art of homo healthcare, or of the science of this, merely not both.
If medicine is defined every bit (a species of) an art, then a stardom must exist made between medicine and medical scientific discipline (and thereby also between medicine and medical inquiry). But if medicine is divers as (a species of) a science, and then information technology is understood to be (quite recent in origin and) not an art (cf. fine art vs science, technê vs epistêmê, above).
Now, there could in principle be two split up entities called medicine, one an art, the other a science. Withal, this duality in the denotation of 'medicine' is nowhere expressly posited. But, as we noted above, the fine art-and-science duality in today's definitions of medicine appears to represent the union of such a pair of very singled-out denotations of 'medicine' – ones that have been adopted in defiance of logic [5].
Academic outlooks on medicine vis-à-vis science
In today'due south medical academia, the outlook on medicine vis-à-vis science involves a salient duality, corresponding to that in medical teaching. There thus is, for ane, the outlook of those teaching the bones sciences of medicine; and in that location likewise is, very distinct from this, the outlook of clinical academics. (Community medicine is not, more often than not, eminently represented in today's medical academia.)
Contemporary didactics of the bones sciences of medicine to medical students grew, as nosotros have described, out of its precursor in medical teaching à la Osler and Flexner. The philosophy underpinning this paradigmatic scientific education of future practitioners of medicine was explicitly well-nigh the essence of medicine vis-à-vis scientific discipline, and it therefore merits existence noted here.
In his seminal written report [2], Flexner proclaimed, without any explication, that proper didactics in modern medicine is "dominated past knowledge that medicine is part and packet of modern science" (p. 53; italics ours). He then sketched the practice of the "scientist" physician in comparison with that of his "empiricist" precursor (still prescientific in his mode of reasoning); and from this he – neither a doc nor a scientist, only an educator – drew the lesson that "Investigation and practise are thus one in spirit, method and object" (p. 56; italics ours). This, also, he seemingly took to be well-known and thus gave no exposition of the reasoning justifying it.
Equally unburdened by any need for explication of his rationale, Flexner treated the first half of the medical didactics at Johns Hopkins – especially the students' experiences in the laboratories of the university's infirmary – as though it were a logically obvious upshot of his premise virtually the essence of medicine. Specifically, he believed that this pedagogy taught the students the scientific way of thinking, which to him was the essence of scientific medicine.
That rationale for the accent on those sciences in the Flexnerian medical education is no longer shared in the basic sciences segment of medical academia. But this has not changed the presence (eminent as ever) of the study of these sciences in medical education. Only the rationale for studying them is new.
For medical students' extensive instruction in the basic sciences of medicine, the rationale now has to do with knowledge. Knowledge from these sciences is said to provide rational medicine – "practice of medicine based upon bodily knowledge; opposed to empiricism" (Dorland'due south). But this substitute rationale for that educational activity besides invites counterpoints.
First, cognition from these sciences is, as we have noted to a higher place, well-nigh pathology, which addresses the objects of medicine (illnesses) rather than medicine proper. This noesis does not therefore embody the principles of medicine definitional to normative, rational medicine.
To wit, Koch's discovery of the somatic bibelot underlying some cases of the sickness that at the time was chosen 'consumption' (or 'phthisis') was a far cry from his having discovered the principles of rational medicine in respect to that illness. (Koch should have called this anomaly/disease mycobacteriosis – à la trichinosis, asbestosis, etc., but instead he redefined tuberculosis equally the illness that is caused by that bacillus.)
Instead of advancing the knowledge-base of rational medicine, this discovery only added to the needs for noesis in the practice of medicine – for diagnoses near the presence of this affliction in cases of that sickness, and for prognoses concerning diverse aspects of the class of the sickness in bodily cases of this illness (including, importantly, the style the prospects depend on the option of treatment).
Second, empiricism of the Hippocratic type (i.e., delivery to learning medicine rationally and from experiences in the practice of information technology) is not antithetical to rational medicine. In fact, it has on occasion been spectacularly instructive about rational medicine. The insights of Edward Jenner and Ignaz Semmelweis are compelling examples of this. (Their insights could not have come from inquiry in the laboratories of the basic sciences of medicine.)
And 3rd, cognition from the bones sciences of medicine is non the modern analogue of medicine'southward prescientific empiricism. Rather, equally we pointed out above, information technology supplants the Hippocratic doctrine about the essence of illness.
The indicate here is that, from the perspective of the bones sciences of medicine — basic, as we noted, not to medicine proper simply to the definition of the objects of medicine (illnesses), and for the development of new products and processes for use in it — null can justifiably be said about the knowledge needed in rational medicine, much less about the larger question of the sense in which, if whatsoever, modern medicine is science or scientific.
Clinical academics would ideally teach the truly requisite scientific knowledge-base of rational practice in particular disciplines of clinical medicine – derived from suitably 'patient-oriented' clinical inquiry. Simply such has been the nature of this research – already very abundant – that this cognition does not still exist (for gaining scientifically knowledge-based insights into the health of patients, in terms of diagnostic probabilities, for a starting time).
These academics therefore continually increase their personal experience in the exercise of medicine (à la Hippocratic empiricism), for one. But besides this, they now also follow 'patient-oriented' clinical research — the publicly documented experiences in it.
This outlook on clinical enquiry in relation to clinical do has, in recent decades, been explicit in the ideology of the 'testify-based medicine' (EBM) motion [six] – an ideology which originated in clinical academia and is at present widely embraced in it (though usually without familiarity with its expressly codification tenets, let alone learned-and-critical thought about these).
This motility'due south original ideologues (Sackett et alii) introduced "clinical epidemiology" as "a basic science for clinical medicine" [7]. Its precepts were intended to provide for practising clinicians a critical agreement of published inquiry on topics relevant to their respective disciplines of clinical medicine. The research that is followed in the practice of EBM bears no relation to the sciences that are addressed in medical education. The research at upshot here is 'statistico-medical' rather than bio-medical.
The nigh key tenet of the EBM motion is that each clinician is to personally follow reports of studies potentially relevant to his/her practice, to critically consider the prove in each of these, then to apply his/her own judgement about the burden of the show (as ersatz cognition) to their intendance of patients [8].
Practise of EBM is thus not noesis-based, or even objectively evidence-based. Its basis is, ultimately, subjectivistic. The practices of EBM are, ultimately, opinion-based. Besides, the teachings in clinical epidemiology are, in of import ways, untenable. (More on this below.)
This EBM culture of today's clinical academics clearly indicates that they practice not view modern clinical medicine equally purely art and, thus, as wholly distinct from science. And more to this upshot is that they expect their 'trainees' to really conduct research in preparation for clinical practice. This fact (odd though it is) reinforces the point that clinical academics see the modern practice of clinical medicine as having an agile scientific dimension (even beyond that which is inherent in EBM). Nevertheless, they don't retrieve of (the practice of) modern clinical medicine as scientific discipline, but as 'clinical epidemiology' and, hence, every bit research-informed art.
The denotation of 'medical' in the science-related phrases above requires clarification. Use of the term 'medical research' – or its cognate 'medical science' – does not inherently imply viewing medicine as a science. The intended meaning tin can be that of medicine-serving research, or science, extrinsic to medicine proper.
Publishing reports on medical inquiry in medical journals as well does not inherently mean that the editors remember of medicine as a science. The reason for this routine tin can (furtively) be the wish to bolster the lay conception of medicine every bit science, equally this public prototype of medicine enhances the status and authority of physicians and cultivates amongst societal authorities the conventionalities that matters medical are across lay agreement, and that medical professions therefore deserve autonomy (in the framework of a 'social contract' to this event). (This motive may too underlie the emphasis on medical science in the education of physicians.)
Our ain outlook on medicine vis-à-vis science
While it is now, as we've outlined here, quite commonplace to hold that the originally pure art of medicine has recently been supplanted, at least in office, by medicine as a science, we exercise not share this view (which has non been affirmed in the public soapbox of relevant scholars).
In our considered view, all of medicine still is, and always will be, purely art (and thus not an amalgam of art and science, let alone purely science). And accordingly, information technology also is our business firm view that all of medical research is extrinsic to medicine proper – that this research is medicine-serving without being (an attribute of) medicine.
The biological research by Pasteur and Koch alluded to above was, as we noted, conducted as piece of work of science in laboratories of science, and thus non as piece of work of medicine in practices of medicine. It exemplifies research in the bones sciences of medicine in both of the two senses in which these sciences can serve the advancement of medicine: those sciences tin can be 'bones' to evolution – technological – of new products and processes for use in the arts of medicine, and to definition (and elaboration) of illnesses (as somatic anomalies).
Research in the basic sciences of medicine is health enquiry in the narrow, absence-of-illness significant of 'health' when addressing the normal structures and functions of the human body. Just in the mutual, broader meaning of 'health', it subsumes research on pathological entities of the soma (representing species of ill health/illness). This inquiry is only contingently medical. It actually is medical merely if it is 'applied' in the sense of existence intended to serve medicine, and even when this is the case, this inquiry rarely leads to innovation in medicine.
This enquiry, as we've argued above, is not the source of the cognition-base of the practise of rational medicine.
Another, very different, major branch of medical research – also extrinsic to medicine proper – is inquiry for the advocacy of the actual cognition-base of medicine proper [9].
Evidence from this enquiry is, as we noted above, the existing scientific addendum to the Hippocratic footing for learning medicine. While it is science in the research pregnant of 'science,' it is not intrinsic to any science. There is no science whose body of knowledge amounts to the requisite cognition-base of an fine art (of medicine or anything else). This is inherently medical research: all of these studies are supposed to contribute to the evidence-base of operations of the knowledge-base of operations of the practices of medicine. This inquiry is, in this sense, quintessentially practical medical research [ix].
At present, fifty-fifty though an enormous amount of research, derivative too as original, of this latter type (statistico-medical rather than bio-medical) has already been published (in medical journals), gimmicky clinical practices are still only opinions-based, rather than (scientifically) cognition-based. Even the so-called bear witness-based medicine is, equally we have noted, no exception to this. (Seeking '2nd opinions' is natural in opinion-based medicine, but not in noesis-based medicine.)
The root reason for this – quite unsatisfactory – situation is, nosotros hold, that the objects of 'patient-oriented' enquiry have not been sufficiently patient-relevant, and therefore information technology has not been possible to translate the evidence from this research into the required knowledge. This problem persists in the 'clinical epidemiology' precepts about 'patient-oriented' clinical inquiry.
Nosotros thus see a need for major transformations in the theoretical framework of this quintessentially applied clinical enquiry, in ii stages [x]. Beginning, at that place is, the demand (ontal) to adopt a tenable conception of the nature (form) of the requisite noesis-base of medicine. Then, subordinate to this, there is the (epistemic) need to adopt a theoretical framework for the research proper such that information technology actually produces the requisite bear witness-base for knowledge of the blazon which truly is needed.
Specifically, the requisite knowledge-base of operations of clinical medicine must exist understood to be of the grade of gnostic – dia-, aetio-, and prognostic – probability functions for suitably defined domains of case presentation for gnosis; and quintessentially applied clinical research – gnostic research – needs to produce valid empirical content in these forms. Furthermore, for each well-designed GPF (gnostic probability function), the results of all valid studies on information technology must exist (synthesised and) translated into a GPF representing knowledgeastward about the magnitudes of the parameters involved — according to the consensus judgment of (representatives of) the relevant scientific customs.
From the perspective of this (quintessentially applied) medical enquiry, whatsoever textbook of modern medicine – naturally specific to a particular medical discipline – would not be organised past any taxonomy of illnesses (à la Osler), but by the types of case presentation that are of concern (for gnoses, first off).
Resolving the art vs science dilemma in medicine
As a summary of sorts of what we've said about medicine in all the foregoing, figure 1 depicts the always-growing and too otherwise e'er-changing 'Tree of medicine', with special reference to scholarly influences on it, from Greek antiquity to the present and beyond. Apart from the original, fundamental influence of Hellenic philosophy, of particular note about this tree in the present context are the two types of research that, while extrinsic to it, have been very important to its evolution. These are the 'basic-applied' and 'quintessentially applied' lines of medical inquiry. They influence, respectively, the roots and the branches of the tree.
An added scholarly influence now is that of critical theory of medicine and medical inquiry. The concerns in this theoretical discipline have, every bit illustrated past this essay, included critical enquiry into the tree'due south evolution up to the nowadays. Its focus now is on charting the hereafter of these two, closely interrelated scholarly fields (medicine and medical research). Recently, the conception of the theoretical framework of 'meta-epidemiological clinical enquiry' for the evolution of the requisite knowledge base of scientific clinical medicine (in terms of gnostic probability functions) has been a major element of these futuristic concerns [ten].
As for progress in medicine, the big moving-picture show from today's perspective is this. While the temple medicine of ancient Greece was supplanted by empirico-rational Hippocratic medicine, and the advent of medical science brought major progress, but nevertheless left modern medicine essentially opinions-based, a radical transformation in modern medicine is now needed. This is the replacement of the prevailing opinions-based medicine with scientifically knowledge-based medicine – by scientific medicine in this significant of the term (very different from Flexner's) – within a rational theoretical framework.
Key to this at present-topical major mission is, naturally, a tenable conception of the in-principle essence of modern medicine, with special reference to the sense, if any, in which it is science. Just, as we have hither explained, there still is, fifty-fifty in medical academia, considerable confusion nigh this.
Nosotros therefore feel the need, now, for learned and thoughtful public soapbox aimed at resolving once and for all the cadre question addressed in the foregoing, namely: has the ancient art of medicine recently become a science in improver to withal beingness an art, or, even, in lieu of this age-old essence of medicine? And closely related to this are the questions nigh the tenable conception of the essence of medical science and that of scientific medicine, which we've also here addressed, to some extent.
Such discourse we expect to converge to common recognition, in medical academia, of modern medicine as the aggregate of its constituent differentiated arts, and of each of them yet being in seriously unmet demand of a scientific cognition-base of operations from research extrinsic to the art – within a tenable theoretical framework.
Implications of our outlook on medicine vis-à-vis science
We expect recognition of our outlook on the essence of medicine to accept major implications in terms of needed reforms in medical academia and, thereby, in medicine proper.
First, we expect it to become appreciated that educating undifferentiated physicians à la Osler and Flexner is no longer called for or even practicable. The graduates of that pedagogy are now merely 'physicians' unqualified to practise any of the disciplines of contemporary (or hereafter) medicine. That 'generalist' education therefore needs to be replaced by education and training (E&T) that is, from its very starting time, preparatory to practice in a particular one of the elective disciplines of medicine, in two stages.
The showtime stage would, but every bit at nowadays, be shared across all the diverse disciplines of modern medicine. Information technology would exist reformed, still, to focus on those educational needs that truly are common across all these arts. Information technology would focus on what in this sense truly is 'the medical common.' Very notably, cognition from the bio-medical sciences is not part of this (as it does not accept applications in vitreoretinal ophthalmology, HIV epidemiology and, also, in each of the other disciplines of modern medicine). Similarly, introduction to whatever subset of the disciplines of contemporary medicine does not belong in a well-construed 'medical common.'
For these first-stage studies to be suitably propaedeutic to the E&T specific to whichever detail discipline of medicine, the very first topic would be the essence of modern medicine – as no longer an art, nor in whatever sense a science, merely equally the amass of its constituent arts, each of them distinguished from the corresponding para-medical disciplines (nursing, amongst others) by the cardinal role of start-mitt gnoses in medicine.
The second, primary stage would, naturally, be subject field-specific. For whatever given student it needs to focus, ab initio (rather than with stage-wise increasing specificity), on the cognition and skills that are needed in the fully competent practice of the particular fine art of medicine the pupil is preparing for.
For whatsoever given clinical subject, this teaching needs to be redesigned to address, first, the spectrum of case presentations in it; then, the profile-conditional gnostic probabilities; and finally, the current land of knowledge about the magnitudes of these probabilities. (The genesis of that knowledge is not relevant to the education.)
This reformation of the cadre part (instruction) of medical academia naturally ways leaving educational activity in the biomedical sciences for other segments of academia to provide (including technological academia) – as preparation for careers in these (rather than in the arts of modern medicine). It too means that a student begins the education and grooming specific to his/her item field of study of medicine much earlier – right after their education in 'the medical common' (paired down to what truly belongs therein).
The research of the teachers of the various arts of mod medicine needs to suit to the core idea – enormously productive – behind the establishment of the showtime enquiry-based academy (U Berlin, in 1810). In these terms, the research of the teachers has advancement of the contents of their own teaching as its raison d'être. With the knowledge-base of a detail discipline of clinical medicine the generic object of a medical bookish's teaching, his/her inquiry needs to be of the form of the suitably-transformed gnostic clinical research.
For that quintessentially-applied (gnostic) clinical research to expeditiously provide for transformation of today's still largely prescientific clinical medicine into its mostly scientific successor, needed is a globally coordinated programme of that research [10]; and also needed is a programme of continually updated translations of the thus-accrued evidence into the requisite scientific knowledge-base of operations of clinical medicine – imbedded in net and guiding, from there, the practices of clinical medicine through scientific 'expert systems.'
Financial disclosure
The Helmut Horten Foundation provided fiscal support through its funding of the Horten Centre for Patient-Oriented Enquiry and Knowledge Transfer.
Potential competing interests
No conflict of interest relevant to this article was reported.
Photograph: © Nimon Thong-uthai | Dreamstime.com
References
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ii. Flexner A. Medical Education in the Usa and Canada. Bulletin Number 4; NY: Carnegie Foundation for the Advancement of Teaching;1910.
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4. Dorland'south Illustrated Medical Dictionary, ed. 32. Philadelphia: Elsevier Saunders; 2012.
5. McCall RJ. Bones Logic. The Cardinal Principles of Formal Deductive Reasoning, ed.2. New York: Barnes & Noble, Inc.; 1952.
6. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. How to Practice & Teach EBM. New York: Churchill Livingstone; 1997.
seven. Sackett DL, Haynes BR, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine, ed. ii. Boston: Lilliputian, Brown and Company, Boston; 1991.
8. Guyatt Yard; Evidence-Based Medicine Working Grouping. Evidence-based medicine. A new approach to instruction the practice of medicine. JAMA. 1992;268(17):2420–5. doi:https://doi.org/ten.1001/jama.1992.03490170092032. PubMed
nine. Miettinen OS. Medicine as a Scholarly Field: An Introduction. Cham, Switzerland: Springer International Publishing; 2015.
10. Miettinen OS, Steurer J, Hofman A. Clinical Research Transformed. Cham, Switzerland: Springer International Publishing; in printing.
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