Wednesday, April 28, 2010

Knowledge: What Kind and How Much?

Here is a second essay from Dr. Robert Goldwyn’s book “The Operative Note:  Collected Editorials” (published in August 1992).  

Knowledge:  What Kind and How Much?

A few years ago, when my daughter was a high school sophomore, she asked me to help her prepare for a biology quiz.  She was astounded that this paterfamilias, a certified physician, was ignorant of the precise base sequence of DNA-RNA.  In self-defense, I said that most of my colleagues would probably fail her test but were good doctors nevertheless.

“but how can they take care of patients properly if they don’t know all about these important nucleic acids?” she asked.

“Surprisingly,” I replied, “they do very well.”

This incident, aside from revealing my daughter’s knowledge and my lack of it, is relevant to the greater considerations of learning – What kind and how much?  Publilius Syrus, known for his maxims in the first centery B.C., said:  “Better be ignorant of a matter than half know it.”  Many centuries later, Alexander Pope expressed the same thought in his famous “a little learning is a dangerous thing.”  Huxley’s retort was “Where is the man who has so much as to be out of danger?”  In truth, most of us are in various stages of ignorance.

A medical student asked me, “How much basic science do I have to know to be a good doctor?”  The question, which may be unanswerable, is nevertheless perennial.  Because knowledge and wisdom are not synonymous, the central query is how much of each is necessary.  Any answer must take into account the individual’s needs at a particular time.  Students regularly complain about the irrelevance of the material they must digest, and teachers constantly chide them for their lack of perspective in not realizing that what may seem useless today may be helpful tomorrow.  What to teach and what to learn have stimulated curriculum committees to produce ponderous reports that rehash everything and resolve nothing.  Rare is the year without another “definitive” statement on the aims and strategies of education.

The human being functions astonishingly well knowing comparatively little.  Global enlightenment is unnecessary.  For most people, making a living in our complex society demands narrowness not breadth.  We are job-specific.  Major league pitchers would fail a high school physics test on mass, velocity, friction, and wind currents, yet they could easily strike out every professor at the Massachusetts Institute of Technology.  So also can a doctor do considerable good for a patient with more know-how than knowledge.  Deplorable, perhaps, but true.

Let us take the example of reconstructing the breast in a 45-year-old woman who has had a mastectomy.  How many plastic surgeons could discourse on the hormones at menopause?  Could we pass a thorough examination on the  various ways of treating breast cancer:  radiation, chemotherapy, surgery?  Are we well read in the history of each of these therapies?  Do we have a picture in our minds of the histology of the most common kinds of breast cancer?  Do we know the chemical structure of silicone and how the implant is made?  During the procedure are we familiar with the anesthetic agents and their pharmacology and physiologic effects?  Do we understand the manufacturing process of the surgical blade and suture material?  And what about wound healing, not only the names of the classic stages but the biochemical and biomechanical aspects?  Certainly, it would be better if we had this knowledge.  However, even if we possessed it, we still would have to know when to operate, on whom, and how.  And what about the not-so-small matter of being a compassionate physician with psychological understanding of this unfortunate person and a feeling of permanent responsibility toward her?

This editorial is not a plea or an apologia for ignorance, not is it a eulogy to it.  It is an attempt to recognize things as they are.  Often we are hypocritical in being hypercritical.  We usually demand more knowledge from others than from ourselves.  Furthermore, within the medical sphere, if we are honest, we would admit that many errors arise not from lack of knowledge but from absence of what moralist one called “character.”  In this situation, what motivates the doctor may imperial the patient to the detriment of both.

Unfortunately, I cannot offer a solution to the problem that prompted this editorial:  Knowledge: What Kind and How Much?  What is certain, however, is that knowledge without wisdom is like a ship without a rudder.  Correct timing and the proper application of  information hopefully come with experience.  Yet, as someone observed, there is a difference between a person who has 20 years of experience and someone with 20 years of 1 year’s experience.  Let us hope, at least, for the former.

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