Understanding and Practice:
How deeply do I understand the bases for my medical decisions? What constitutes practical understanding?
I practice a high stakes type of medicine: hematology and oncology. My patients have life threatening diseases. Patients expect a highly educated, highly informed opinion about how to proceed. They believe that I understand the medical research that forms the basis of the treatment plans. What does it mean: "to understand"?
Understand is a word that consists of two components: under and stand, both easily comprehended English words. I can imagine this combination of words to mean having a relationship with the subject that does not crush me, I can stand under the image and look at it objectively and agree. I can bring supporting ideas to bear on the issue, see the basis of the conclusion.
To understand disease and treatment has a variety of its own meanings. There is a quantitative aspect to understanding, it can be broad or narrow, superficial or deep. Using these terms to describe understanding reflects its architectural nature. Understanding is a structure. If it claims to be tall its foundation must be very deep, it can easily topple, a poorly supported claim of understanding is a very insecure structure.
Within medicine, within oncology, understanding means different things. Evaluating microscopic images requires a set of cognitive skills that is quite different from evaluating the statistics of clinical trials outcome data. The interpretation of large data sets that describe outcomes is very separate from that molecular biology that describes the mechanisms of disease and recovery. Once a particular type of interpretation is relegated to an expert, without review by the deciding physician, it become religious scientism, faith in a vaguely understood process, believed on the basis of a report there is an unrecognized underpinning of pure faith. It is the intelligent integration of the various facets of information that constitutes understanding. Understanding requires skepticism and self criticism.
The practice of medicine requires sufficient understanding to know when to use a given therapy and when not to. It implies a knowledge of how to administer the treatment and how to deal with its consequences. Unfortunately, in our rapidly changing world, depth has become optional.
Often, the understanding is quite superficial. It consists of recognizing a pattern that identifies a disease, reviewing sets of guidelines or published recommendations; deciding among the various alternatives; beginning treatment; and dealing with consequences. This pattern of behavior is not simple and requires a high degree of education and intelligence. But it is not what I call understanding.
In our era,we have come to question the value of deeper understanding . The big data approach suggest that the analysis of a large enough data set will yield a better set of predictions than a model of disease and treatment based, theoretical "understanding" of (an imagined) underlying mechanism. There is undoubtedly a role for this kind of agnostic knowledge. But, an approach that denies any level of mechanistic understanding may fail to identify the heterogeneity of the data set and obscure important information. In the large dataset we are often naming a number of diverse entities the same diagnosis. We now recognize some of these differences and separate the abnormalities that will reliably respond to their special treatments, but this process of differentiating molecular diagnoses is in its infancy. It is only begining to penetrate clinical trials.
What we currently call a diagnosis usually does not correspond to a single molecular entity. A diagnosis today is a combination of a clinical history, physical and radilogic findings, a particular microscopic appearance with certain stains, an aberrant collection of surface molecules, and/or a set of mutations in critical genes. Whe the diagnostic lable is attached , there is often no recognition of the methods used to arrive at the diagnosis. Sometimes one set of methods is applied, sometimes another
What we currently call a diagnosis usually does not correspond to a single molecular entity. A diagnosis today is a combination of a clinical history, physical and radilogic findings, a particular microscopic appearance with certain stains, an aberrant collection of surface molecules, and/or a set of mutations in critical genes. Whe the diagnostic lable is attached , there is often no recognition of the methods used to arrive at the diagnosis. Sometimes one set of methods is applied, sometimes another
The important, practical goal is the identification of a distinguishing mark that directs therapy, the piece of information that will lead to cure. Finding that is something I can support. When I have that piece of information, in a practical sense, I understand.
