Thought barriers to understanding rheumatic diseases--Halstead R. Holman revisited

Halsted R. Holman, in a 1994 Arthritis & Rheumatism editorial, discusses how "thought barriers" can make our understanding of rheumatic diseases more difficult. The medical teaching-practice has traditionally been centered on acute disease; however, most rheumatic diseases are chronic. There is also the prevailing notion of a single lesion for each disease, a concept stemming from infectious diseases. Related to this is an investigative strategy of reductionism. We commonly overlook interactive biological pathways, which make up many of our diseases. In this regard, Holman advises us that 1. abnormalities are not necessarily harmful; 2. in rheumatological diseases, not only are multivariate causes-pathways operative, but the same pathways can be influenced by separate influences; 3. in chronic disease, "the task of the physician is to manage the course of disease over time," a scheme where the patient is at the center of achieving and monitoring progress; and 4. our current medical care system is mainly based on acute care, and needs to be adopted more to the needs of chronic care. In the current manuscript, three additional "thought barriers" are proposed: 1. our urge to lump diseases is too simplistic and hinders progress; 2. the same is true for our resistance in not including diseased control groups in genetic association studies; and 3. misuse of the controlled clinical trial. The popular inductive reasoning with the propensity to prove rather than to falsify one's self might be the common denominator in many of the barriers discussed.