Thursday, November 21, 2013

Knowledge is The Food of Clinical Intuition (Part One)

What we seem to have forgotten as a profession is that the scientific knowledge of medical school and the academic science beyond that are not end in themselves. They are the means to a greater end. It is a necessary step along the way to becoming an exceptional human clinician who has applied scientific knowledge and understanding as a part of a greater human context for both doctor and patient.

Knowledge and evidence are fragments. Theories are the patterns that tie the individual pieces of knowledge and evidence together to make them predictive. However, theories are linear and generally only tie two strands of knowledge together to create a small section of a greater jigsaw puzzle.

That is what we learn in scientific medicine. We learn one system at a time, organ by organ. We also learn to think like that, to use the mindset of empirical, laboratory science. It is to form a foundation for what comes next. The physician on the path to greatness builds on this, adding to it and braodening their horizons and the amount of information can be added. The scale and complexity of their puzzle expands to encompass other realities such as the patient's psychology and social situation.

For the clinician, science is the kindergarden for thought. It is a safe environment in which to learn the basics. Simple answers can be checked and fed bacck upon before entering the complexities of the real clinical world. The importance and culture of objectivity can be learned under simple and safe conditions before being put under very serious pressure and challenges in everyday human health.

The ability to think clinically is ever more important with the mass of evidence that is available in the modern world. Often it is conflicting evidence from experts and studies approaching the same subject from a different point of view. The academics have the luxury of having a cozy little debate about it but clinicians somehow have to make sense of the conflicting evidence and make life and death decisions on that basis. The academic tradition is to make linear arguments that hold together by deprioritising or excluding the inconvenient evidence and basing their opinion on other learned opinion rather than the gold standard of consistency with the entirety of the evidence available. Doctors cannot safely do that.

The Arts of Clinical History and Clinical Examination are external, easily identified and taught in medical education and training. The third basic clinical art is clinical thinking, an invisible, internal process. Perhaps it is the most important of the three basic arts of medicine because it is this that takes all of the information from the first two arts, plus the technological results to produce the diagnosis. It deals with the evidence to put it into practice on a case by case basis and creates complex treatment plans. However, the art of clinical thinking is rarely discussed and never directly taught. It is a process of consciousness beyond scientific description. It is a subjective human experience.

All that we hear of from science is their occasional anecdotes of genius where massive conceptual breakthroughs are made. Einstein called this imagination. Watson is said to have dreamed the double helical structure of DNA and designed his experiments around that inspiration. Newton was meditating on the universe under a tree when struck from above by the metaphorical apple of knowledge.

Such great inspiration is a rare, unreproducible mystic event in academic science. Inspiration is so rare because it cannot and will not be taught. However, I have had the privilege to work for and with some absolute clinical geniuses. I can tell you that they live and work in this inspired state of mind where jigsaws of disconnected facts fall together into perfect harmony. They fall together into perfect consistency.

This state of mind can be described. What it feels like to think like this can be communicated. The path to attaining and living this higher level of clinical thought can be illuminated. It can be practiced and learned.

This thinking comes from a cleverer part of the mind. It is a higher part of the mind, what Freud called the Super Ego. We could even call it conscience, that higher part of the mind that sees the greater picture and rebukes us for egotistical and myopic decisions. It is there in everybody but it is silent. It is the quiet voice. It is the tranquil voice of the still mind.

This part of the mind from which inspiration and true intuition come is there and available to anybody, not just clinicians. What makes it inaudible is the constant chatter of the conscious mind and the rollercoaster of emotions from the subconscious. Inspiration in sifting through complex evidence, applying theory in practice and making difficult diagnoses with a mass of subjective observations that the linear consciousness just finds too confusing comes from the silent mind. It only comes to the silent mind.

Inspiration comes to the truly objective mind. The Noble Scientific Ethic of Objectivity is the exclusion of all subconscious emotion and vested interest. For better, hope and wishful thinking must be excluded. For worse, fearing the worst must be excluded. The clinician must be able to deeply trust themselves in this or they will not trust their inspiration. That only comes from accustomed living of that objectivity. It comes from living the medical ethic of always putting patients' health first and going beyond the call of duty regardless of how the clinician feels. That is what establishes new subconscious habits that can be trusted.

This is the habit of thinking first rather than letting emotions make decisions. If the emotion agrees with the decision, enjoy it. Use it as physiological motivation to drive that objective, rational and informed decision home.

Only once that habit has been established can a clinician innately trust the objectivity of their own mind. They no longer have to question it. They have no self-doubts because they know deeply that personal interest, including acting for patient popularity never enter their mind. They know that they intrinsically do the right thing and are uncompromising and uncompromised in putting the patient first and going beyond the call of duty.

It is in this silent, still mind that the evidence floats freely. When there is no pressure of inner words or emotions, the pieces of the puzzle twist freely. The evidence is certain. The interpretation is not. Suddenly, the hard evidence falls into place and it all makes sense whichever way you look at it.

True inspiration always makes rational sense. Its linear logic always works. It has just selected one of a variety of possible rational explanation for the evidence, even originally think a rational explanation that has not been considered or investigated before. It has selected the only linear explanation that is consistent with a wealth of other information. Perhaps more to the point, it always agrees with all scientific first principles.

Counter-intuitively, I will say don't take any piece of scientific knowledge too seriously. Take it light-heartedly whether you like it or not. Enthusiasm corrupts the process and subjectively prioritises it. Objectivity is being lost. Instead, think something neutral. Examine the study design and statistical process. Bore yourself so the new knowledge is unweighted.

The Super Ego is clever than the conscious mind. Trust it. It will all be in there. You will simply remember the most amazing details from years ago that you thought you had forgotten when they are needed so long as they are left floating freely. The higher parts of the mind will simply select them when necessary.

The more you know, the better the process works. It gives the hgier parts of the mind more pieces of the jigsaw to play with. It cannot be overloaded. Trust it. If you have once experienced its marvels, you will trust it.


Dalya Ferguson, MD said...
This comment has been removed by the author.
Dalya Ferguson, MD said...

I have to comment that I disagree strongly that a clinician ever reaches a point of having no self-doubt or trusting one's objectivity completely. Questioning one's motivation is the very practice that allows human beings to make objective decisions. We are not naturally objective and, in my opinion, can never "become" objective. We can, however, recognize our motivations and choose not to act based on those that are less than ideal.

Doctor Which said...

I have met a few clinicians who have reached this stage but it is not what you think. They have absolute self-confidence that their decisions are as good as possible.
This is the result of their absolute dedication. They know that they could have done no more. Not only have they gone beyond the call of duty and been uncompromising in that patient's care but also in their dedication to their personal development as a clinician and human being which includes to know everything possible. It is all about personal development towards selfless altruism. All subjectivity is in the end egoism.
Their lack of self doubt is for their uncompromising fulfilment of their vocation. They know that nothing more could have been asked of them. They have taken every decision in the truest faith, including their objectivity. That comes from selflessness that has been indoctrinated into their heart and soul.
What more can anybody ask of a doctor? What more can they ask of themselves?
This is how the ethic doctor sleeps peacefully at night. They know unequivocally that they did their best. It is also what gives them certainty in their decisions.

Do not expect to have certainty over the outcomes of clinical decisions. All decisions are risk benefit analyses and sometimes the dice roll against you. That does not mean that the decision was at fault.

Do not expect certainty that present medicine will tell you the right thing to do. Five years down the line, that could all change. Doctors used to promote bedrest and exercise avoidance.

All that you can do is to make decisions on the very best information at the time. Fears that the information is not perfect will paralyse you. It causes indecision and hesitation and that can cost lives.

All that you can do is your best under the circumstances. If you know from the depths of your heart and soul that that is what you have done, you will not doubt yourself.