The Profiterole Theory of Medicine

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Is medicine a hard science or a soft science?

Hard sciences are quantitative, rigorous, and mathematical. Their hypotheses are precise and their predictions reproducible, with a high degree of control over variables and conclusions.

Examples include math, physics, chemistry, and astronomy.

Soft sciences are more qualitative, relying on statistical analysis of empirical data. Their hypotheses tend to be more general and their predictions less precise, with variables and conclusions that are difficult to control.

Examples include psychology, sociology, and economics.

Auguste Comte, a 19th century French philosopher, considered by many to be the first philosopher of science, originally came up with these distinctions in an attempt to create a descriptive hierarchy of the sciences. 

Ironically, Comte put the hard sciences - starting with Astronomy - at the bottom of the hierarchy, and the soft sciences - with Sociology, which he thought of as being the queen of them all - at the top. 

But as anyone who has spent time in academia knows, this hierarchy has long been reversed.

The soft, social sciences suffer a definite inferiority complex with respect to the hard, physical sciences, often manifesting itself in overeager attempts to out-rigor the rigorous, with complicated mathematical models and computer algorithms.

Unfortunately, the results are mixed at best, undermined by the wonderful and maddening unpredictability of human beings. As philosopher Paul Feyerabend put it: Prayer may not be very efficient when compared with celestial mechanics, but it surely holds its own vis-a-vis some parts of economics.

The same could be said vis-a-vis some parts of medicine. 

While medicine claims to ground itself in the hard sciences - the premedical curriculum is made up of calculus, physics, chemistry, organic chemistry, and biology - the deeper you get, the softer the ground becomes.

Take obesity and weight loss, for example. 

It’s hard to think of an area of medicine where the science is so clear-cut.

How do you lose weight? Eat less, move more. It’s pure math - and not even calculus but simple arithmetic. Body weight is a direct function of energy balance. When caloric intake exceeds caloric output, you gain weight; conversely, when caloric output exceeds caloric intake, you lose weight. 

There are no exceptions to this rule, and every single diet in the universe - not to mention medical innovations such as medications or bariatric surgery - must create a caloric deficit to cause weight loss. There is no magic involved, and as far as the scale is concerned, it makes no difference whether the calories come from brussel sprouts, steak, or Haagen-Dazs; protein, carbs, or fat.

Yes, there is such a thing as metabolism, which does vary from person to person, and does slow down in response to weight loss, which complicates the picture at the margins. But that just means the system is dynamic, not that the model is flawed. As a Russian teacher of mine once memorably put it, in the Gulag there were no fat prisoners with slow metabolisms.

From a medicine-is-hard-science perspective, then, we have solved weight loss. So why is it so hard to achieve in practice, with real patients in real life?

In order to understand the answer to that question, you need to dive off the rocky cliff of hard science, and into the cool waters of the soft sciences.

You may want to start with psychology, which is uncovering all sorts of ways in which restricting calories to lose weight can create psychological dynamics that result in the opposite effect. These range from all-or-nothing mentalities that amplify small lapses - if I eat one cookie I may as well eat the whole box - to more extreme pathologies like binge eating disorder. 

From there, why not move on to economics, and the complex interplay between the diet industry and the food industrial complex. 

My favorite book on this topic is still the Omnivore’s Dilemma, by Michael Pollen, where he reveals the staggering amount of research and development that goes into making processed food so addictive that we end up having to overcompensate to resist it.

Put it this way: the idea of the Paleo diet makes a lot more sense when you understand how Doritos are engineered so that you can’t stop eating them until the whole bag is gone. 

Food, Inc. makes us fat, and then delivers us into the hands of Diet, Inc. to make us thin again. There is a lot of money being made on both sides of that deal.

On a deeper level, why do we care so much? A lot of weight loss is motivated not by health but by appearance. Why allow ourselves to be manipulated? Why not just be satisfied by who we are and how we look and move on?

To understand the answer to that question we have to leave the realm of science altogether and go softer still, into the Humanities.

There is nothing really new (under the sun) about how advertising, social media, entertainment, and other cultural influence(r)s present us with idealised and unattainable versions of ourselves that we strive toward, against our own interests, with such profound discontent. Writers and thinkers have been talking about such things for thousands of years.

Which finally brings us to Art, the softest and most ancient practice of them all. What does Art have to teach us about the meaning of food and the problematics of dieting? Proust’s Madeleines come to mind, the pastries whose taste spark 3,000 pages of feelings and memories in his masterpiece, Remembrance of Things Past. 

Do I really want to be the doctor who says to Proust: Marcel, you really need to lose a few pounds, but don’t worry, it’s easy! Just stay away from those Madeleines…?

Maybe I do. But not without some insight into the implications of what I am suggesting and some understanding of the forces that I am sending him up against. That is the soft side of medicine that I believe you need, along with the hard side, in order to practice it well.

(True, you may need it more in Family Medicine than in Neurosurgery, but as long as you are treating human beings, you still need it more than you might think.)

Telling people to change the way they eat - it’s a big ask. It’s like… like…there is no good metaphor. Food is the metaphor. 

In that spirit, permit me to use a food metaphor to answer my initial question. 

One of my favorite writers, Adam Gopnik, wrote a piece in the New Yorker, back in 2002, about food and chefs. In it, he quotes a certain chef as saying, “No matter how varied you think your technique is, you always end up taking something flabby and making it crunchy on the outside, tender on the inside. Food is always crispy out and tender in, over and over and over again.” (Every time we go out to eat I am amazed anew at how true this is!)

Is medicine a hard science or a soft science?

Like a profiterole, it’s both. Crispy out, and tender in. Over and over and over again.