Knowledge, Experience, Reality, and Wisdom

1
Knowledge, Experience, Reality, and Wisdom

• Some Implications for Medicine
• Myles N. Sheehan, S.J., M.D.
• Loyola University Chicago Stritch School of
  Medicine

2
Goals

• Use Critical Realism as a way to provide a set of
  frames for educators to deepen their
  understanding of medical knowledge
• Consider the problems of realism in our culture
  that often denies reality

3
Objectives

• Recognize limitations of standard methods of
  evaluation of medical knowledge in assessing the
  competency of learners
• Describe stages of acquiring medical knowledge,
  pitfalls, and promise
• Explain the meaning of terms techne, phronesis,
  sophia in light of the maturation process of
  clinicians
• Identify an approach based on critical realism in
  forming trainees as they grow in medical knowledge

4
Pitfalls

• Using philosophy and Greek terms can easily be
  construed as pompous and self-promoting rather
  than a genuine way to think more deeply and
  understand

5
Some aphorisms to lay the groundwork

• Theres nothing more dangerous than a medical
  student at the end of his/her third year
• She knows what she does not knowand then
  figures it outgreat resident.
• After twenty years of practice, I recognized how
  little I knew despite being quite current in the
  literature, up on the evidence, and skilled in my
  specialty

6
What do you know?

• Heparinizing a GI bleeder whose intravenous lipid
  formula accidentally was bolused when a clamp
  broke, leading to respiratory distress
• Who knew about heparin induced induction of
  lipoprotein lipase?
• Who knew about heparinizing an actively bleeding
  person?

7
Grounding in reality

• Jacques Maritain 1886-1963
• Realist versus idealist
• I am, therefore I think NOT I think, therefore
  I am.
• Reality is situated in the experience of being
  ideas are not real in and of themselves

8
So what?

• Approach to the Patient With CHF
• No such person
• Disease as the biomedical grid we place on the
  experience of personsthat experience is called
  illness. (Kleinman)
• Sweeping ideas and idealized constructs are not
  unique to medicinejust think of some of the
  unreflective approaches to cultural competence.

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Ideas remain important?

• Ideas and knowledge organized theoretically
  provide a way to begin to map the territory of
  reality
• We can meet a person with CHF without any
  knowledge of CHF and miss a lot
• We need to have an understanding of the
  pathophysiology of CHF and still recognize the
  person who has the illness
• Thats what medical knowledge is about

10
Knowledge, skills, attitudes

• Not sure this tripartite division works as neatly
  as it might seem
• Knowledge as a skill that grows depending on
  ones attitude
• Techne, phronesis, sophia
• Hubris and humility

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Dreyfus Model of Skill Acquisition

• Three transitions
• From working on the basis of abstract
  principles to working on the basis of past
  concrete experiences
• From seeing situations as composed of equally
  relevant bits to discerning situations as
  complete wholes with certain relevant parts
• From acting and knowing as a detached observer to
  acting and knowing as an involved participant
• (from Dartmouth Medical School c 1996)

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Dreyfus Model, continued

• Novice
• Advanced beginner
• Competent
• Proficient
• Expert
• Master

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Techne

• Knows physiology and pathophysiology
• Has a basic grounding in history taking and
  physical diagnosis
• Has a basic understanding of pharmacology

14
Techne approaches CHF

• A disease characterized by inability of heart to
  pump enough blood to meet the needs of the body
• This can be because of excessive need or a
  problem with the heart
• Excessive need would be because of
  hyperthyroidism, anemia, blood loss

15
Techne continues with CHF

• Heart problem can be with left ventricle, right
  ventricle, or both, it can be caused by problems
  in systole or diastole
• There is a differential diagnosis for the cause
  of the heart problems
• Systolic Heart failure is manifest usually by
  edema, pulmonary congestion, and an extra heart
  sound (S3)
• It is treated with a diuretic, an ACEI, and
  digoxinmaybe spironolactonemaybe beta blocker.

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Techne meets Mr. Jones

• CC, HPI, PMH, SH, FH, ROS, PE, Labs, Rays, AP
• 70 yo man with history of two previous MIs
  presents with worsening SOB, DOE, weight gain,
  and edema with exam showing tachycardia,
  tachypnea, rales, gallop, edema.

17
Phronesis and Mr. Jones

• CHF admission in the ER
• Want to get a troponin, CK, and CXR in the ER,
  check ECG, get an O2 sat, see if sick enough for
  unit consult
• Admit to tele, r/o MI, schedule echo, diurese,
  cards consult, consider cath
• After above, dig, ACEI, continue diuretics,
  discharge in 48 hrs

18
Sophia and Mr. Jones

• Knows the need to work him up and discharge him
  rapidly
• Wonders how the frail wife will cope and if the
  meds can be paid for
• Knows the residents plans are good, but not sure
  if the patient will comply
• Expect that Mr. Jones will initially do well but
  wonders if he can live with his illness and
  change his life

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A series of frames of experience

• Basic issues of disease
• The issues of hospital management
• The person with the illness and the circumstances
  of his life
• A life in a family with or without resources
• A family in a culture that expects cures,
  comfort, certainty, and service
• A world where tears are still part of the nature
  of things

20
Implications for learner growth

• Developing the skill of knowledge is the
  ability to grow in understanding of detail while
  grounding it in the reality of a person, the
  system/s of care, the culture (local and larger)
• Wisdom and mastery is manifest by recognition of
  multiple shifting variables that limits ones
  knowledge, recognizes the provisional nature of
  medical decisions, and often the uncomfortable
  feeling that one is not doing enough

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Growth in knowledge

• Nothing wrong with technical knowledge or
  practical wisdom.
• Over-reliance on these as the ideal is dangerous
  and leads to mistakes in the grounded reality of
  individual patients
• Mastery and wisdom recognize how many things are
  uncontrollable and shifting and seeks to provide
  the best care for the person realizing best may
  not always be clear

22
Art or science?

• A false dichotomy often claimed by those who are
  incompetentlack both techne and phronesis
• Evidence and best practices are always based on
  populations
• It takes humility, command of the knowledge base,
  and clinical skill to apply it to a person

23
Growth in knowledge suggests growth in engagement

• When the developmental stage of competence is
  reached, it is said to be accompanied by a
  qualitatively different kind of emotionality and
  sense of responsibilityIn a situation where
  postulants and novices were untouched at any deep
  emotional level, our experts were affected
  deeplyTheir sense of responsibility played a
  part in their feelings as well. Expert
  teachers, apparently like other experts, show
  more emotionality about their successes and
  failures in their work. David Berliner. The
  Development of Expertise in Pedagogy. 1988, p. 19

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Wisdom in a foolish age

• Disease is situated in a person
• A person is cared for in a particular system
• That persons care is influenced by bio-, psycho,
  and social considerationslike family
• The person, family, exist in a larger culture
• That culture despises mortality, uncertainty, an
  inability to control and fix.
• Can mean the best doctors can carry a lot of
  conflict

25
Critical reality and formation of physicians

• Much written and spoken criticizing physicians
• Little written or said about the reality of an
  impossible task
• The impossibility comes from the lack of ability
  to keep what are in our culture implied promises
  and expectations of perfection, cure for all
  disease, global sensitivity, and omniscience.

26
Implications

• A culture that despises complexity,
  provisionality, and mortality can create the
  hidden curriculum for medical knowledge
• The hidden curriculum of students and residents
  often reflects a marked preference for technical
  knowledgeif you know the facts you can avoid
  the reality
• Evaluations on exams can reinforce the false
  notion that the ideal is the real and reality is
  not to be explored

27
A puzzle

• I feel deeply frustrated by suggestions to demand
  more developmentally out of our trainees than
  anyone could expect from individuals mainly in
  20s and early 30s.
• I also recognize the need to face the multiple
  failings of how physicians can interact with
  patients
• It is easy to overwhelm those growing in the
  skill of knowledge when confronted with the
  reality based expectations and the unreal
  expectations of those who seek care and their
  families

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A puzzle (continued)

• How does one encourage continued growth in the
  reality of complexity as experienced in the care
  of patients while maintaining excellent technical
  and practical levels of knowledge?
• How does one avoid overwhelming the developing
  learner with layers of detail?

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A need for role models

• Students and physicians have their own experience
  of reality
• Limiting that experience to clinical facts and
  treatments provides a measure of safety for them
  that is bad for those they treat
• Opening up to the wider world of knowing a
  patient is dangerous and hard and takes time
• Need physician guides who are wise to help out
  and lead people to grow

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Importance of those who form students and
residents

• Need role models, not someone who just gets a
  salary in between grants
• Need role models, not simply old war horses
• Need role models who are exemplary in technical
  and practical wisdom and have the wisdom to show
  others the importance of facing a complicated
  reality rather than settling for the illusionary
  ideal of medical knowledge

31
Summary

• Medical knowledge is a skill improved with
  deepening experience
• It has layers of technical knowledge, practical
  or common sense, as well as wisdom
• Facing the multiple facets of the lived
  experience of those persons whom we care for
  involves all these layers
• Limiting medical knowledge to the technical and
  practical exchanges critical reality for an ideal
  that does not exist

32
Summary

• An ideal of medical knowledge that does not
  confront reality provides protection from the
  difficulty of practicing in a very challenging
  world
• It derives from the unreality of our larger
  American culture that favors the technical over
  the personal, the easier answer over the right,
  the promise of a cure over the promise of caring
  and healing when cure is not possible

33
Summary

• The challenge of those who form physicians is to
  allow them to grow and deepen their knowledge
  while recognizing this is a process and not a
  moment
• Careful attention to those who do the formation
  suggests the need to select masters who are
  respected by students and residents while also
  willing to allow the complexity of reality to be
  part of the knowledge they impart.