medical education | wellnessrounds

A few weeks ago one of those “scary” messages popped up on my car’s dashboard screen.

Next step – get on the internet.

It turns out that the key thing is to look at the grille shutter to see if there is anything stuck in it. If it’s stuck open there isn’t a problem. If it’s stuck close it’s still not life (or car) threatening unless the engine overheats. Sounds straightforward… but, you have to know where to look.

Since (of course) we were over 200 miles from home when this happened, we went to the local dealer and asked if there might be someone who could look to see if it was stuck open or closed.

“We’d have to run a full diagnostic scan first.”

“But we just need someone who knows where to look to just look.”

“We can’t do that. There aren’t any technicians available and they require the scan first.”

(At this point we decided to take our chances and assume it was open)

“You know, we are both doctors…”

He interrupted to say “So you know how important CT scans are!”

I smiled and said, “Not if all you need to do is pull out a splinter.”

from *The Making of a Diagnostic Mind* by Alexandra Sifferlin

The art of diagnosis in medicine starts, very importantly, with the story. It’s actually astounding how often that will make the diagnosis. At the very least, it narrows down the possibilities. (which we call “the differential”).

The physical exam is next, to refine the differential diagnosis and guide you in deciding which tests to order. Even if the triage team has ordered the tests first (like in a busy ER) it’s still very important to go through these steps in order, starting with a “blank slate” so you don’t fall into the trap of the many ways our brains succumb to bias (especially anchoring bias).

What makes this process, the art of diagnosis in medicine (as opposed to my car) unique is the intent. Because we always go through this process for someone else. We make a diagnosis as the first, important step in healing another human being.

Birding is about healing ourselves

We don’t “diagnose” a bird when we go birding. There are some similarities – We look at “field marks” and listen to the songs the same way we collect data from a patient. We also create a “differential” i.e. the list of birds that fit our findings.

But there’s is one big difference – the intent. Birding is not something we do for someone else, it’s something we do for ourselves.

Photo by Mary Brandt (on the way to High Island via the Bolivar Flats)

There’s a reason so many people flocked (no pun intended) to parks during COVID to take up birding for the first time. It’s a focused way to be outside and experience a little bit of forest (or lake, or field) “bathing”…to connect with sounds and sights that resonate on a soul level.

Anyone who birds a favorite park over and over knows intuitively why they keep going back: It just feels good. Being in nature—pausing in it, sitting with it, discovering its wonders—brings a sense of calm and renewal.
audubon magazine

Discernment is about healing the world

And then there’s discernment, which comes from a different, deeper intention.

“Discernment” implies more than than just identifying a bird or making a diagnosis. We discern the difference between right and wrong, the correct path in our career, which of two important choices we should make … in other words, discernment helps us find our way in a moral or spiritual sense. Which is why discernment can be is a spiritual practice based on “noticing the movements within your heart and soul — your desires, thoughts, emotions — and identifying where they are coming from and where they are leading you.”

Compassionate action emerges from the sense of openness, connectedness, and discernment you have created.
Joan Halifax

The definition of “knowledge” in English is pretty straightforward – To “know” something means being familiar and/or aware of it in a way that lets us understand. I find it fascinating that English has only one word for “knowledge”, where other languages use multiple words to reflect the depth and nuances of the concept. “Once widespread in Germanic, the verb [to know] is now retained there only in English, where it has widespread application, covering meanings that require two or more verbs in other languages (such as German wissen, kennen, erkennen and in part können; French connaître “perceive, understand, recognize,” savoir “have a knowledge of, know how;” etymonoline

How we understand “knowledge” affects how we teach, how we learn, and how we see the world.

The philosophers of Ancient Greece saw acquiring knowledge as an important part of the human quest for wisdom. Enter episteme, techne, phronesis, gnosis, and doxa. These nuanced ways to think about knowledge and wisdom have a lot to offer us as we navigate the misinformation and philosophical chaos of our time. For those in medicine, these nuanced definitions add beautiful complexity and understanding to our work, with special inspiration for those who teach the healing arts.

Episteme: Intellectual knowledge (Root of “epistemology”, the study of knowledge)

This is the information we learn in our classrooms, from books, and from teachers.

A crowded anatomy classroom scene featuring medical professionals in white lab coats surrounding a patient on a table, engaged in discussion and observation. — The Anatomy Lesson of the Irish College of Surgeons, Robert Jackson, 2010

Techne: Technical knowledge (Root of “technology”)

Techne refers to the technical skills of a profession – the grasp of grammar for a writer, pedagogical skills for a teacher, the ability to perform specific procedures for a surgeon.

Two surgeons in surgical attire engaged in a procedure in an operating room, depicted in a stylized manner. — Photo by Mary L. Brandt, MD

Phronesis: Practical wisdom

I recently read this remarkable essay by Sami Sinada in which he states: “Medical school teaches episteme. Residency builds techne. But phronesis? We assume it appears through osmosis. It doesn’t.”

The entire essay is well worth your time to read, but Dr. Sinada makes an important point – Our medical school and residency curricula have gaps when it comes to teaching practical wisdom (which is the core of doctoring). He goes on to argue that we can close that gap with five important pedagogical choices:

Start with uncertainty, not answers.

Prioritize continuity over episodic care.

Use ethical cases as judgement training.

Make expert reasoning audible.

Require reflective writing.

A 19th-century painting depicting a doctor seated next to a sick child lying on a bed, with concerned family members in a dimly lit room, conveying a sense of care and concern.

Doxa: Common belief, popular opinion. (Root of orthodox)

What strikes me about doxa is that it has no moral weight associated with it. Doxa can refer to the deep orthodoxy of thousands of years of tradition in a culture … everything from how we greet each other to what we believe… as well as culturally accepted, politically motivated lies.

An infographic illustrating different greeting customs around the world, showcasing interactions in various countries with visuals and descriptions. — Source

Gnosis: Insight, deep personal knowing

Gnosis is most often associated with gnosticism, a religious and philosophical movement in the 2nd century. But I wonder if the concept of a deep inner knowing (whether or not you view that as divine) isn’t worth refurbishing for our time as an important way to “know”. Contemplation, meditation, prayer can all open spaces that defy our intellectual understanding, leading to a way of “knowing” that, in some ways, we need now more than ever.