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Saturday, February 6, 2010

Medical Knowledge vs. Medical Know-how

I have been listening to a series of lectures by Professor Stephen Goldman of the Departments of Philosphy and History at Lehigh University. The lectures are entitled "Great Scientific Ideas that Changed the World". For those of you who have not heard of the Teaching Company, it is a great company. The lectures offered are generally interesting and extremely well delivered by the best professors in the US. If you get them on sale, they are very reasonably priced.

But back to Dr. Goldman's lectures. He traces back the history of knowledge and makes a distinction that I never really gave much thought to, a distinction which I believe has relevance to medicine and medical education. According to Dr. Goldman, knowledge which benefited humanity has existed for tens of thousands of years but Greek thinkers (Plato, Socrates, and Aristotle) made a distinction between knowledge and know-how and this distinction has impacted Western thought in particular since that time.

Know-how knowledge is knowledge practical, concrete, and historical in the sense that it changes over time as experience changes over time. But that would mean, since this  knowledge changes with experience, it cannot be timeless.There were philosophers in ancient Greece, the Sophists, who defended such an idea of knowledge.

Plato and Aristotle defended a totally different definition of knowledge, based upon the mathematical teachings of Pythagoras and Parmenides. They defended a definition of knowledge as universal, necessary, and certain and their definition of knowledge was that something can only be called knowledge only  if
it is universal, necessary, and certain. For them, knowledge was timeless.

"What is fascinating is that this highly abstract and intellectualized definition of knowledge has been dominant in Western cultural tradition, in the Western intellectual tradition, to the very present. And in fact, it was the definition of knowledge that was built into science, built into modern science as it emerged in the 17th century, and continues to be the case. Mathematical knowledge, notice, is timeless, in addition to being universal. We don’t expect triangles to change or to change their properties because we have moved from the 19th century to the 20th century, or because we have moved from the 20th to the 21st, or moved from Europe to Africa, or from Africa to Asia. Mathematical knowledge is universal, it’s timeless, it’s necessary, it’s certain.
It is the paradigm of knowledge for ancient Greece, and it is always referred to, right into the modern period, when there are challenges raised against this definition of knowledge, which flies in the face of experience. So that’s a fascinating fact about Western culture, about Western intellectuals, philosophers and scientists alike, that this definition of knowledge has been absorbed."

Medicine and medical education straddles between these two worlds. Medical educators generally live in the University, which is steeped in the Greek belief system of knowledge. Legitimate scholarship in academic medicine aspires to be timeless, necessary, and certain. However, medicine is also a craft and the effective practice of medicine requires practical knowledge to apply any timeless knowledge which may be the product of scholarship.

Medical education occurs in environments where there are multiple interfaces between knowledge seekers and know-how seekers.  Because of this environment, medical education suffers from the same sort of disdain that Plato and Aristotle had for the Sophists and their reverence they held for practical knowledge. However, without practical knowledge, process suffers, and without effective process, patients will be hurt.

For years, the practical part of medicine was openly self taught. I was trained the environment of see-one, do-one, teach-one. How obvious can one be? It was viewed as essential for me to memorize the details of every available biochemical pathway, an exercise that I now realize was sort of the medical school equivalent of memorizing bible verses. Actually developing the practical skills required to be an effective physician was acquired by basically throwing us in the deep end of the pool and we were expected to swim. The most highly regarded professors were too busy trying to generate knowledge that was timeless, necessary, and certain, not the ones who worked on actually effectively deploying such knowledge to the benefit of patients.

Roll the clock forward and not much has changed. Reward and highest acclaim in academic medicine still goes to those involved in generating knowledge as viewed by Plato and Aristotle and not the practical Sophists. I suspect that as long as medical education is centered in universities who hold fast to the Greek perspective of knowledge, nothing will change.

Education in general is in many respects shares the same schizophrenic role as medical education. Do people go to universities to learn a trade or do they go there to learn knowledge which is timeless, necessary, and universal? The information revolution and the innovations made possible by new tools is set to disrupt this paradigm. Perhaps the time is right for a new Flexner-like revolution in medical education to happen.

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