BLOG: We cannot know everything always

ByDaniel J. Acevedo, PA-C

There are many versions of the phrase “I know that I know nothing” or “I know one thing: that I know nothing.” Although it is widely debated, this phrase is attributed to Socrates. In Plato’s Apology, Socrates says, “I am wiser than this man, for neither of us appears to know anything great and good; but he fancies he knows something, although he knows nothing; whereas I, as I do not know anything, so I do not fancy I do. In this trifling particular, then, I appear to be wiser than he, because I do not fancy I know what I do not know.”

I am fond of this phrase, but the more I examine the wording, it mostly sounds like boasting. He inevitably says that he is smarter than the other Greek. My favorite version of this phrase comes from Diogenes Laërtius’ Lives of Eminent Philosophers: “I know nothing except the fact of my ignorance.”

To not know is okay

Every day in medicine we are utilizing years of acquired knowledge to treat the patients before us. Patients present to us in the clinic or on the hospital wards and we catalog their historical information and examination findings into that 3 lb. organ in our cranium and we assign a diagnosis. This assessment comes from not only countless hours of reading and note taking but from experiences on rotations and working clinically as we practice the art of medicine.

We cannot know everything always. In reality, we will be stumped. When faced with a presentation of an orthopedic ailment unlike anything in a textbook or from clinical experience, I am always impressed with those who given the answer, “I do not know what is going on.” I will use this phrase from time to time. There is no failure or defeat in its utterance. It is wise and humble. We use other modes of technology, like imaging or blood work. We ask colleagues. We may even treat with the minimum effective dose of a drug with the working diagnosis of one malady in hopes another may or may not declare itself with observation. Not knowing is one vital aspect of medical practice we must recognize. Another and even more important component is the ability to continuously learn and strive to be on the cutting edge of medical knowledge.

Every 6 years to 10 years, depending on when they graduate, physician assistants (PAs) embark on their recertification cycle. There is nothing more humbling than reviewing topics from otolaryngology and ophthalmology to infectious disease and cardiology. Medical knowledge is changing rapidly and has been doing so for decades. In the last 5 years since I graduated PA school, I have seen a dramatic shift in how we treat labral tears of the shoulder, the length of stay of after total joint replacement and the treatment of certain fractures. I know these things, not intuitively, but because of working day-to-day in my chosen subspecialty and collaborating with physician colleagues.

But what about diabetes management or the treatment of hypertension? In that same time, there have been changes to the diagnostic criteria of hemoglobin A1C and caution in aggressively treating hyperglycemia in type 2 diabetics. The Eighth Joint National Committee has expanded its criteria from the previous committee’s stance on the treatment of hypertension. Progress in evidence-based medicine continues and the onus is on the providers to catch up.

Be lifelong learners

Gillam and colleagues note that medical knowledge in 1950 doubled every 50 years. For those practicing medicine or in school, that rate will change to 73 days – an incredible statistic. Being a lifelong learner is not just something we like to espouse on interviews and in descriptors of our profession. Being a lifelong learner is a necessity and requirement. Beyond dusting off the cobwebs of primary care medicine, as I am doing now, it is imperative to learn the updated knowledge and treatment criteria of problems seen daily.

The cost of not keeping up-to-date on medical knowledge is not just personal and professional. We all enjoy the process of learning and will do what we can to increase our effectiveness as providers. However, there still exists a discrepancy with utilizing new information. A 2003 report from the Institute of Medicine found it takes an average of 17 years to adopt a new discovery into clinical practice. This has significant societal costs. Ludmerer noted that only half of adults receive the care recommended by U.S. national standards.

There is clearly so much we do not know. What do we do? Luckily there are passionate educators and providers who use the Internet and digital media to close knowledge gaps. Most hospital libraries provide free access to the top medical journals and websites in our field. Memberships to specialty societies provides access to their catalog of journals and CME material. Physician Assistants in Orthopaedic Surgery partnering with the American Academy of Orthopaedic Surgeons instituted access to “The Yellow Journal” with its membership, which has been a game changer in my pursuit of the best, most up-to-date knowledge.

Embrace learning

It all begins with the acknowledgement of what we do not know and our desire to be better. For PAs in practice and for those students in school, there is no better time to embrace learning and the limitless access to information. Moreover, share your ideas with others. Talk to colleagues about that conference you attended, articles you read or the podcasts you listen to on the ride to work. Take an active role in teaching in your institutions or local PA programs. This has always been a way for me to keep on top of pertinent, essential subject material.

Socrates was wise in affirming his humility in the pursuit of knowledge. It is an important first step in the process of learning. However, I look forward to a time where we can embrace the phrase, “I know only that I can know more and do more…for myself and for my patients.” Luckily, this is an era where we have access to more information as it evolves than ever before. Let us work together to meet that goal.

References:

Gillam M, et al. The healthcare singularity and the age of semantic medicine. Available at: http://research.microsoft.com/en-us/collaboration/fourthparadigm/4th_paradigm_book_part2_gillam.pdf

Ludmerer KM. Time to Heal: American Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press; 1999.

Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.

Daniel J. Acevedo, PA-C, is a board-certified physician assistant who practices at the Orthopaedic Center of Central Virginia in Lynchburg, Va. His research interests include physician assistant education and precepting, osteoarthritis, and periprosthetic joint infections.

Disclosure: Acevedo reports no relevant financial disclosures.