"Medical Ignorance, Failure, and Chaos: Shifting Paradigms for the 21st Century"
1995 American
Academy of Family
Physicians, Dr. Marlys H. Witte, (MD), University
of Arizona School of Medicine
Transcribed from a tape-recorded lecture by Kathy Dettwyler, apologies for any errors.
Dr. Lewis Thomas, MD/philosopher/author, 1983: "The greatest single achievement of science in this most scientifically productive of centuries has been the discovery that we are profoundly ignorant. We know very little about nature and we understand even less. I wish there were some formal courses in medical school on medical ignorance, textbooks as well, although they would have to be very heavy volumes."
Perhaps we need blank pages in our textbooks for things we don't yet understand.
A course in medical ignorance would be an appropriate activity for ailing medical education.
Doing this at the University of Arizona -- developing a curriculum that would teach students how to recognize and deal with medical ignorance.
Epistemology -- theories of knowledge
Nepistemology -- theories of non-knowledge
What are the terrains, what are the landscapes of ignorance? A conceptual map of the lands of the unknown:
1. The known unknowns -- the things we know we don't know, and we research them, we admit them as questions. 2. The unknown unknowns -- the things we don't know we don't know, or the things we didn't know until recently we didn't know (the discoveries of tomorrow).
3. The things we think we know, but don't -- look at old textbooks and see all the things we thought we knew, but didn't.
The Dean of Harvard Medical School tells incoming students that by the time they graduate, 50% of what you learn in medical school will be proven, in 10-20 years, to be false. The problem is, we don't know which half.
4. The unknown knowns -- the things we don't know that we know, the tacit knowledge, the taken-for-granteds.
5. The taboos, the dangerous, polluting, or forbidden knowledge ª- that lead us not to ask the questions that are important.
6. Denial -- all the things too painful to know, so we simply don't know them, don't want to know them.
This terrain of ignorance is always changing, it is symbiotic with knowledge, it's mutually permeable, multi-dimensional, and interactive, and it is thoroughly interdisciplinary.
The domain of ignorance, rather than a void, or an absence, or a vacuum, is a plenum, a cornucopia really of a fertile terrain of these many areas that we don't address in medical school.
The domain of ignorance is truly the terrain of all learning – you can't learn something you already know, and all discovery – you can't discover something you already have. So that all learning and discovery takes places in this terrain -- it is toti-disciplinary, and one can take a specific topic and define all of these areas of ignorance.
That is the content of the curriculum. How do you teach people to think about these things?
We teach young children NOT to ask questions. If you had a logo or a label, it would be "No Questions". The curriculum on medical ignorance suggests that you should ask questions. Difficult to overcome teaching not to ask questions. Ask for all the questions you have about any topic -- uncork all the questions, release the inhibitions, begin to talk about the things we don't know.
Type 1 questions Basic, fundamental questions
Type 2 questions
Clinical management questions
Type 3 questions
Go beyond the patient, to society, legal/ethnic/social questions
Point is to get the student to ask the question, even if there isn't an answer. The simplicity of the words won't tell you if something is an important or valuable question.
Recognizing your ignorance is the first step. The humility of that recognition, which is important to wisdom.
A paradigm shift -- as the information society was developing and the idea that knowledge was greater than information and leads to wisdom.
"Education is to train our students for what no one knows today and everyone must know tomorrow."--Margaret Mead
Two sub themes:
failure and chaos
What can we learn from failures? Both our own and others? You learn the most when you lose and you analyze it. Not signs of defeat, but preludes to success. Edison said that his greatest strategy for success was to design failure into the system, because he learns from the thousands of approaches that don't work. Mistakes were inevitable. If you try to do it completely right the first time, to design a system that is foolproof, you will fail. And he recognized that it was important to admit and analyze your failures. Are mistakes put in the closet and not discussed, so that performance can't really be improved.
Chaos -- complexity and order within disorder.
As the sphere of knowledge enlarges, so too does our contact with the unknown. The more you learn, the more you know you don't know.
Goals:
To gain an understanding of the shifting domains of ignorance, uncertainty, and the unknown; to improve skills to recognize and deal productively with ignorance, uncertainty, and the unknown, and these skills include questioning, communicating and collaborating, and then to reinforce the positive attitudes and values of curiosity, optimism, humility, self-confidence, and skepticism.
A research project is a question mark. A voyage into ignorance. Begin with questions, end with other questions.
Researchers come in and talk about their questions, what they don't know, and how their questions have impelled them to seek answers.
For whatever topic you choose: focus on specific topics and then uncover what is not known about the topic. The focus is on what is NOT known, which requires a great deal of work to find out what IS known, critically evaluate it, think and spend time and say what don't we know about this topic.
Distinguished ignorami -- visiting professors. One seminar is on everything they know about X. Then they give a seminar on "La Residencia del Incognito" and they talk about what they don't know. All the questions they had, and still have, or have now, about their topic. No books, slides, papers allowed.
Ignorance exercises. Ignorance Log: every week students have to list a whole set of questions and what they're doing about answering these questions. The back of the paper must also be filled with questions.
Creative thinking exercise: "grow your own organ" exercise. Mother gave baby piece of her liver. Basic biological questions, practical clinical questions, moral/ethical questions.
Monthly pondering rounds for the medical school. Students and faculty come in and bring their "ponders" of the month – things they've been thinking about and pondering about in response to lectures and readings. Failure rounds -- focus directly on failures. How failures are dealt with; admitting failures and then moving on.
Questions don't have to have answers.
What are the questions that are the most current and important in the field, and who/how/where are people going about answering these questions.
[There should be a] Web page for ignorance on the Internet.
How much ignorance can you take? Some people have problems dealing with the uncertainty, the exploration of discovery, the creativity, involved in the ignorance curriculum.
How do you evaluate the curriculum, if the skills and competencies have been acquired, what has the impact been? See by the progress of the questions. Comments of the students.
Medicine is a prisoner of a vast array of biases and dogma, that we are ignorant of what causes problems for our patients.....
Focus at least one eye somewhere over the horizon.
Enthusiastic ignorance....
Write down an instance where your ignorance helped or hindered you.
Ignorance is a virtue, I think.
Ignorance is a part of the life of every living being, it is the reason for living. You cannot know everything about everything, you cannot even know everything about one particular object.
“Yes, we have no pat answers”
Medicine has lots of words from Latin and from Greek.
We conceal our ignorance with classic double-speak.
So we go about our rounds, explaining things away.
Though with more humility, we might come clean one day
And tell you,
Yes, we have no pat answers. We have no pat answers today.
What we have is congestion of question on question with certainty far away.
With luck we'll help our patients respire until we retire, but
Yes, we have no pat answers. We have no pat answers today.
The End
Dr. Lewis Thomas, MD/philosopher/author, 1983: "The greatest single achievement of science in this most scientifically productive of centuries has been the discovery that we are profoundly ignorant. We know very little about nature and we understand even less. I wish there were some formal courses in medical school on medical ignorance, textbooks as well, although they would have to be very heavy volumes."
Perhaps we need blank pages in our textbooks for things we don't yet understand.
A course in medical ignorance would be an appropriate activity for ailing medical education.
Doing this at the University of Arizona -- developing a curriculum that would teach students how to recognize and deal with medical ignorance.
Epistemology -- theories of knowledge
Nepistemology -- theories of non-knowledge
What are the terrains, what are the landscapes of ignorance? A conceptual map of the lands of the unknown:
1. The known unknowns -- the things we know we don't know, and we research them, we admit them as questions. 2. The unknown unknowns -- the things we don't know we don't know, or the things we didn't know until recently we didn't know (the discoveries of tomorrow).
3. The things we think we know, but don't -- look at old textbooks and see all the things we thought we knew, but didn't.
The Dean of Harvard Medical School tells incoming students that by the time they graduate, 50% of what you learn in medical school will be proven, in 10-20 years, to be false. The problem is, we don't know which half.
4. The unknown knowns -- the things we don't know that we know, the tacit knowledge, the taken-for-granteds.
5. The taboos, the dangerous, polluting, or forbidden knowledge ª- that lead us not to ask the questions that are important.
6. Denial -- all the things too painful to know, so we simply don't know them, don't want to know them.
This terrain of ignorance is always changing, it is symbiotic with knowledge, it's mutually permeable, multi-dimensional, and interactive, and it is thoroughly interdisciplinary.
The domain of ignorance, rather than a void, or an absence, or a vacuum, is a plenum, a cornucopia really of a fertile terrain of these many areas that we don't address in medical school.
The domain of ignorance is truly the terrain of all learning – you can't learn something you already know, and all discovery – you can't discover something you already have. So that all learning and discovery takes places in this terrain -- it is toti-disciplinary, and one can take a specific topic and define all of these areas of ignorance.
That is the content of the curriculum. How do you teach people to think about these things?
We teach young children NOT to ask questions. If you had a logo or a label, it would be "No Questions". The curriculum on medical ignorance suggests that you should ask questions. Difficult to overcome teaching not to ask questions. Ask for all the questions you have about any topic -- uncork all the questions, release the inhibitions, begin to talk about the things we don't know.
Type 1 questions Basic, fundamental questions
Type 2 questions
Clinical management questions
Type 3 questions
Go beyond the patient, to society, legal/ethnic/social questions
Point is to get the student to ask the question, even if there isn't an answer. The simplicity of the words won't tell you if something is an important or valuable question.
Recognizing your ignorance is the first step. The humility of that recognition, which is important to wisdom.
A paradigm shift -- as the information society was developing and the idea that knowledge was greater than information and leads to wisdom.
"Education is to train our students for what no one knows today and everyone must know tomorrow."--Margaret Mead
Two sub themes:
failure and chaos
What can we learn from failures? Both our own and others? You learn the most when you lose and you analyze it. Not signs of defeat, but preludes to success. Edison said that his greatest strategy for success was to design failure into the system, because he learns from the thousands of approaches that don't work. Mistakes were inevitable. If you try to do it completely right the first time, to design a system that is foolproof, you will fail. And he recognized that it was important to admit and analyze your failures. Are mistakes put in the closet and not discussed, so that performance can't really be improved.
Chaos -- complexity and order within disorder.
As the sphere of knowledge enlarges, so too does our contact with the unknown. The more you learn, the more you know you don't know.
Goals:
To gain an understanding of the shifting domains of ignorance, uncertainty, and the unknown; to improve skills to recognize and deal productively with ignorance, uncertainty, and the unknown, and these skills include questioning, communicating and collaborating, and then to reinforce the positive attitudes and values of curiosity, optimism, humility, self-confidence, and skepticism.
A research project is a question mark. A voyage into ignorance. Begin with questions, end with other questions.
Researchers come in and talk about their questions, what they don't know, and how their questions have impelled them to seek answers.
For whatever topic you choose: focus on specific topics and then uncover what is not known about the topic. The focus is on what is NOT known, which requires a great deal of work to find out what IS known, critically evaluate it, think and spend time and say what don't we know about this topic.
Distinguished ignorami -- visiting professors. One seminar is on everything they know about X. Then they give a seminar on "La Residencia del Incognito" and they talk about what they don't know. All the questions they had, and still have, or have now, about their topic. No books, slides, papers allowed.
Ignorance exercises. Ignorance Log: every week students have to list a whole set of questions and what they're doing about answering these questions. The back of the paper must also be filled with questions.
Creative thinking exercise: "grow your own organ" exercise. Mother gave baby piece of her liver. Basic biological questions, practical clinical questions, moral/ethical questions.
Monthly pondering rounds for the medical school. Students and faculty come in and bring their "ponders" of the month – things they've been thinking about and pondering about in response to lectures and readings. Failure rounds -- focus directly on failures. How failures are dealt with; admitting failures and then moving on.
Questions don't have to have answers.
What are the questions that are the most current and important in the field, and who/how/where are people going about answering these questions.
[There should be a] Web page for ignorance on the Internet.
How much ignorance can you take? Some people have problems dealing with the uncertainty, the exploration of discovery, the creativity, involved in the ignorance curriculum.
How do you evaluate the curriculum, if the skills and competencies have been acquired, what has the impact been? See by the progress of the questions. Comments of the students.
Medicine is a prisoner of a vast array of biases and dogma, that we are ignorant of what causes problems for our patients.....
Focus at least one eye somewhere over the horizon.
Enthusiastic ignorance....
Write down an instance where your ignorance helped or hindered you.
Ignorance is a virtue, I think.
Ignorance is a part of the life of every living being, it is the reason for living. You cannot know everything about everything, you cannot even know everything about one particular object.
“Yes, we have no pat answers”
Medicine has lots of words from Latin and from Greek.
We conceal our ignorance with classic double-speak.
So we go about our rounds, explaining things away.
Though with more humility, we might come clean one day
And tell you,
Yes, we have no pat answers. We have no pat answers today.
What we have is congestion of question on question with certainty far away.
With luck we'll help our patients respire until we retire, but
Yes, we have no pat answers. We have no pat answers today.
The End
