When We Mistake What We Can Know for All There is to Know

The problem is that once science has reduced a complex phenomenon to a couple of variables, however important they may be, the natural tendency is to overlook everything else, to assume that what you can measure is all there is, or at least all that really matters. When we mistake what we can know for all there is to know, a healthy appreciation of one’s ignorance in the face of mystery like soil fertility gives way to the hubris that we can treat nature as a machine.

Michael Pollan, 2007

These nicely crafted words are by Michael Pollan in his book: the Omnivore’s Dilemma: a Natural History of Four Meals. Michael Pollan was describing what happened to the health of plants when we reduced what they need to Nitrogen, Phosphorus, and Potassium (NPK). We started providing plants with NPK only (through synthetic fertilizers). Michael Pollan states: once we reduce complex phenomenon to a couple of variables, however important they may be, the natural tendency is to overlook everything else. This is exactly the problem with the misapplication of evidence based medicine (EBM). There is the tendency to overlook everything else. EBM is a very good tool for evaluating studies. These studies happen to follow the reductionist paradigm. We should never allow reductionism to overcast our thoughts. We should not allow EBM to overlook everything else and assume there is nothing else to know.

Knowing What Must be Done Does Away with Fear

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I have learned over the years that when one’s mind is made up, this diminishes fear; knowing what must be done does away with fear

- Rosa Parks

This is another marvelous quote cited in the book I am reading: Iconoclasts, a neuroscientist reveals how to think differently; by Gregory Berns. The book tries to find what make up iconoclasts. Berns defines iconoclasts as people who do things others say cannot be done.

Over multiple chapters, Berns describes the deleterious effects of fear on innovation. Fear not only prevent people from taking actions but can also change their perception. If perceptions are faulty, the actions taken based on these perceptions will most likely be faulty.

How does this relate to family medicine?

One of the main types of fears Berns describes in his book is the fear of the uncertainty. In practicing family medicine this fear is a fact of life. Rosa Parks states that knowing what to do go away with fear. I can rephrase this for practicing family medicine:

knowing about most illnesses diminishes fear; knowing clinical approaches for different patients’ presentations go away with fear.

Many of family medicine text books and articles do focus on algorithms to approach the problems patients come with. However, if we consider how people (including physicians) actually think, we would end up with slightly different texts. In psychology, people first categories problems and then device their decisions and actions based on these categories. Experts categories are different than novice categories. Experts categories are more detailed. Here are examples:

• lay person: Diabetes
• novice physicians: Diabetes type I, Diabetes type II on oral hypoglycemic and Diabetes type II on insulin
• experts: young Diabetics on oral hypoglycemic, old diabetes on oral hypoglycemic, diabetics on two injections per day of mixed insulin, diabetics on extended release insulin and a fast acting insulin, and so on.

Having texts and articles that address all these categories is not practical. However, addressing a category level called ‘basic’ category is worth it. Basic category is the word people use when asked: what is this? If I point to a coffee table and ask you to name it: will you say a table ,or a piece of furniture, or a coffee table? If you guessed a table, then you are right. Table is a basic category is this context. Basic categories will differ according to the level of expertise. If a carpenter is asked to name the coffee table; s/he will probably call it a coffee table and not just a table.

Basic categories as ‘table convey enough differentiation compared to the more general category: furniture. A table is quite different than a couch which is also furniture. Table also has enough specificity when compared to ‘coffee table’. ‘Coffee table’ is more specific, but this added specificity is not always needed. (Lamberts & Shanks 1997)

All experts acquire basic categories naturally; with practice. Experts have mature categories compared to novice. Having text books and articles that address basic categories may speed family physicians transition from novices to experts.

At the end _however we classify illnesses_, in family medicine we should focus on patients’ presentations and having well thought of, evidenced based approaches to go away with the fear of uncertainty.

Lamberts, K. & Shanks, D., 1997. Knowledge, Concepts, and Categories MIT Press ed., The MIT Press.

Seeing With New Eyes

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The real voyage of discovery lies not in seeking new landscape but in seeing with new eyes.

- Marcel Proust

I passed by this quote in the book I am reading by Gregory Berns: Iconoclasts, a neuroscientist reveals how to think differently. I cannot shake this quote off my mind. Berns defines iconoclasts as people who do things others say cannot be done.

As I try to make connections to my previously read book: In defense of food, an eater’s manifesto, I can see a different future. A future without today’s crippling chronic illnesses as diabetes, coronary heart disease and osteoarthritis. I think we need to look beyond current studies on insulin, cholesterol and glucosamine. We need to move quickly beyond debates as what should our LDL or A1c targets be.

We should always seek new eyes. We should never limit ourselves by ‘current evidence.’ Current evidence leads to expected current outcomes.

In Michael Pollen's book ‘In defense of food’ he describes clinicians that practiced during the turn of the previous century. (1800’s into the 1900’s) These practicing clinicians had different eyes than ours. They saw a world without these degenerative diseases and saw them spread. They saw the spread of these diseases with the invasion of the industrialized western diet. If we see through their eyes and use Greogory Berns findings on needed features of iconoclasts, may be, we will see a world without these illnesses.