Physicians and knowing what you do not know

The famous philosopher F. Bacon, also known as the father of positive sciences, addressed King James I of England in 1605, complaining about the universities of Cambridge and Oxford at the time, and summarized his thoughts as follows: “There are distempers prevalent in our universities. The most prominent of these is that professors have for some time begun to focus on words rather than things.” Bacon’s main grievance was that instead of solving the secrets of nature through proper observation, professors would hide behind flowery words—usually in Latin—to sound scientific while merely expressing their own opinions. Bacon’s observation about words versus things has been used for centuries to condemn pseudo-science.

Another pair of terms used to examine the quality of scientific endeavor are “splitters” and “lumpers.” While their origins are often attributed to C. Darwin, it is certain that Bacon also made this distinction. Splitters are intent on showing how different each observation they make is from similar observations. The main preoccupation of lumpers is the effort to emphasize how much their observation resembles other similar observations. Both parsley and mallow are green plants that grow in the soil. However, they differ greatly in some of their characteristics. Darwin, the pioneer of plant classification, therefore said, in a literal translation, “Both those who split hairs and those who lump are good.”

Then there are the criteria-setters, who are particularly relevant to medical science. Between us, we could also call them those who pontificate. I truly do not know the history of criteria-setting in science. But if you wish to scoff at it as merely a personal observation, 60 years ago, medical schools taught the Jones Criteria used in the diagnosis of acute rheumatic fever—you know, that disease that can cause permanent heart damage alongside joint involvement, usually resulting from a streptococcal throat infection in childhood. These criteria, which were frequently asked about in exams, were soon realized to be useless and were forgotten. Today’s medical education also features numerous sets of criteria. Examples include criteria for rheumatoid arthritis, lupus, multiple sclerosis, and Behçet’s syndrome. The usefulness of all these criteria in diagnosing individual patients is quite limited. There are two main reasons for this. First, our knowledge regarding the prevalence of the diseases I have listed in the environment where the physician works is generally quite insufficient. I do not know if the rule that every probability depends on the one preceding it is still taught in secondary education.

The second reason is that although medical science is much more successful in overcoming the diseases I have listed compared to, say, 50 years ago, it has not yet fully clarified the exact cause or causes of some diseases, the mechanisms of disease formation, or which treatment method will restore our patient to health and in what timeframe. Therefore, while guidelines can be prepared for the diagnosis of these diseases, preparing criteria is beyond us. Perhaps the most difficult job among us belongs to psychiatrists. The causes and exact courses of almost none of the diseases that concern them are fully known. It is precisely for this reason that the American Psychiatric Association has been publishing diagnostic manuals for psychiatrists every 10–20 years since 1952.

In summary, as a very experienced medical student, my observation is that although medical science has progressed greatly in the last half-century, there is still much that remains unknown. The way to overcome this lack of knowledge, as Bacon emphasized centuries ago, is to refrain from naming the unknown, to avoid making clusters with what we do not fully know, to be as analytical as possible instead, and to be as stingy as possible in creating disease criteria of questionable utility in the path to diagnosis.

Look, for centuries, medical schools have taught us what we need to know as a physician, a researcher, or both. What we do not know is almost never addressed. Yet, the most valuable knowledge is knowing what you do not know. Some attribute this saying to Confucius, others to Socrates. The famous humorist M. Twain says, “It’s not what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”

My suggestion is that from now on, courses, seminars, or talks on “what we do not know” regarding relevant fields should be added to medical schools, specialty training programs, and all medical congresses. I am of the opinion that such a practice would bring both physician-patient relationships and the functions of private or public institutions supporting medical services to a much more honest and efficient level. It is in the nature of the profession for a physician not to know some things, and sometimes very important things, and this needs to be well understood by other stakeholders of medical services, starting with the physician themselves.