How, despite having about a full academic year of medical education under my belt, can I still feel so inadequately prepared when I’m tasked with interviewing and examining patients?
This question has been clamoring for my attention recently because of a certain experience I had a few weeks ago at the St. Vincent’s student clinic. My patient was an older woman who had been having left-sided chest pain intermittently throughout the day for several weeks. After reviewing her chart, I took her vitals, listened to her heart and lungs, and asked her some questions I thought were pertinent to the pain. Pretty basic stuff. But when I left the room and presented the information I had gleaned to a couple of clinic directors, I was asked a rather unsettling question: “Does the patient have chest pain now?” The question was eminently logical. The patient had been having chest pain every day; today was, well, another day; therefore––it would have been reasonable for me to have inferred before I was asked the unsettling question––the patient was quite possibly having chest pain this very minute. It didn’t even cross my mind that this could be the case, though. Embarrassed and worried, I rushed back to the room and asked her, with a hint of urgency, how she felt. She was fine, she said; no chest pain, nausea, sweating, or anything ominous. In short, nothing to worry about. Whew!
There are several reasonable explanations for my negligence that day, perhaps the main one being that I had never worked with a patient experiencing persistent chest pain. (Cute little MS1 that I am, I still have precious little clinical experience.) But there is one explanation I find particularly interesting, and that relates more to the nature of medicine than to those who practice it. To understand it, we’ll need to make a brief (very brief, I promise) foray into epistemology, the branch of philosophy concerned with the nature and acquisition of knowledge.
Predictably, philosophers have distinguished between all sorts of knowledge. We’ll focus on just three types here. First, there is propositional knowledge, or knowledge of facts (i.e., true propositions), such as that Seattle gets more snow than Galveston annually, or that––mirabile dictu––penguins have knees. Next, there is know-how, which is knowledge of how to do things; for instance, how to repair a bike, or how to make plum pudding. Finally, there is knowledge by acquaintance, which can be thought of as knowledge of something gained by coming into direct contact with that thing. All of us have, for example, knowledge by acquaintance of what it feels like to breathe, since (unless the reader happens to be a jellyfish, or something like that) we’re all breathing.
Of course, one could make a decent case for the claim that there are no hard and fast lines between these three types of knowledge. It could be pointed out, for instance, that propositional knowledge relies on knowledge by acquaintance, since one must obviously be acquainted with a proposition before one can know it. (Indeed, with this sort of reasoning it could be contended that all knowledge is knowledge by acquaintance.) Nevertheless, the distinction between the three types seems rather intuitive, so let’s roll with it.
Was that very brief? I happen to think so, but I really don’t know.
Now back to the business of explaining my blunder in St. Vincent’s a few weeks ago. To practice medicine––to practice medicine competently, that is––one must acquire a great deal of knowledge, knowledge which comes in all three of the forms described above. Medical propositional knowledge includes knowledge of physiology, anatomy, pharmacology, pathology, and everything else one has to know about humans to oversee their medical care; medical know-how includes knowledge of how to perform a thorough physical exam, how to efficiently interview patients, how to interpret radiographs, and the like; and medical knowledge by acquaintance includes, at a minimum, knowledge gained through meeting and interacting with one’s patient or (if not working with the patient directly) through reviewing the patient’s information.
All of this knowledge must come together in the clinician’s head when they’re at work, and it must do so with a considerable degree of organization. If the clinician can’t use their knowledge, if they don’t know when and how to draw upon their propositional knowledge, know-how, and knowledge by acquaintance as needed, then they won’t be able to provide optimal care to their patients. And, to make matters much more complicated, the three types of knowledge will invariably influence one another as the patient encounter progresses, due to how closely related each of the types are in the clinic.
My patient encounter from a few weeks ago can illustrate these abstruse points. The three things that I want to elaborate upon with reference to this case are:
(1) the knowledge relevant to the case,
(2) the organization of this knowledge in the clinician’s mind (supposing that a true clinician rather than yours truly had done the initial evaluation of this patient), and
(3) the interaction of the three types of knowledge within the case.
Let’s start with the knowledge relevant to the case; the propositional knowledge, in particular. Without a doubt, there’s a ton of facts for the clinician to know, facts about basic cardiac physiology, common signs of cardiac dysfunction, physical findings for cardiac dysfunction, risk factors for cardiac dysfunction, cardiac conditions that can cause non-radiating left-sided chest pain, any other conditions that could cause this sort of pain, and much more. Next is know-how. In this case, know-how encompasses, first and foremost, what to listen for on auscultation of the heart and lungs, and it also includes how to test for other standard features of cardiac dysfunction, such as swelling in the legs. Lastly, there is the knowledge by acquaintance of the patient, which includes an awareness of her past medical history, how she looks today, what she has to say about her symptoms, and related matters.
That’s a summary of the knowledge this patient’s doctor needs to treat her competently. Next we have the organization of this knowledge in the clinician’s mind. All I’d like to observe here is that the clinician doesn’t need to recall every last bit of medical knowledge they have when caring for this patient, and within the particular storehouse(s) of knowledge they find it necessary to revisit, not all of the contents contained therein will be equally important. It seems far more important in this case––to give a humdrum example––for the clinician to know the typical and atypical signs of an acute heart attack, than to know how this patient’s ejection fraction could be calculated using ultrasonography.
Last is the interaction of the three types of knowledge within the case. This, as I’ve suggested, is where things can get really messy. Once the visit begins, with every passing minute the clinician will acquire more and more knowledge about the patient, mostly of the by acquaintance sort. The knowledge acquired will, in turn, help the clinician to determine what questions to ask, how the physical exam should be structured, and what tests to order, if any. In other words, the knowledge acquired will decide how the clinician will use the knowledge they already have, and how they will seek out the knowledge which they want but don’t have.
Imagine that, in the case under scrutiny, the clinician has plenty of propositional knowledge about both heart attacks and muscle cramps of the chest. Now imagine that the patient tells the clinician that she has the chest pains sporadically, and that she feels sweaty and lightheaded whenever she has them. With this valuable knowledge by acquaintance of the patient’s symptoms, the clinician can henceforward concentrate upon their propositional knowledge of heart attacks since, given her symptoms, the patient is more likely to be at risk for a heart attack than for recurrent muscle cramps of the chest. If, on the other hand, the patient had informed the clinician that she was a powerlifter, and that she felt the chest pain primarily following strenuous workouts, then the clinician would probably have to rely more on their propositional knowledge of muscle cramps of the chest.
Being rather simplistic, this example captures only a sliver of what would be going on inside a clinician’s mind during an actual patient visit. If we were to somehow take a peek inside their mind at such a time, we would see crowds of propositional knowledge, know-how, and knowledge by acquaintance contending for the clinician’s attention, swelling in some parts, diminishing in other parts, and going through all sorts of intricate motions as the patient visit proceeds. Indeed, there’s a pretty good chance that amidst the conceptual bedlam we would find a massive disco ball spinning around on the ceiling.
Disco balls or no, there is a lot of knowledge clinicians and clinicians in training have to keep track of when seeing patients, and this puts them (particularly the latter) at risk of overlooking something important in the clinic. This, I believe, is what happened to me last week: I got so caught up in knowledge about my patient and her potential conditions that I forgot to ask her how she was feeling right then and there. That, and I didn’t have enough experience with patients experiencing chest pain to reflexively ask her how she was doing when I first learned about her recent symptoms.
What I’m trying to say with all of this heady stuff is that practicing medicine competently is hard, and that a major reason why it’s hard is because it draws on the three types of knowledge discussed here––three types which interact with one another in intricate ways in the clinic, and that are tough to properly organize when it comes time to do so.
If that sounds like bad news, I can confirm that it is, in a sense, bad news. But there is also good news, even if the news is quite well-known. It is that, with ongoing study and practice, we humans can obtain and hold onto vast amounts of knowledge, no matter what it is we’re learning about, and that in time we can even come to know how to use the knowledge that’s at our disposal. So, while practicing medicine competently is hard, it’s definitely doable.
You got that, David? Good. Now hit the books.