Not Knowing What You Don’t Know: Is Ignorance Ever Bliss?
As I see it, there are two aspects of “not knowing what you don’t know” as applied to health and medicine. One is related to the behavior of the physician and the other is related to the behavior of the patient.
A physician who does not know what information is missing from his or her medical knowledge or understanding may be diagnosing and treating patients with a mental blinder. Doctors simply cannot know about everything clinical and indeed there is some information that is simply unknown to all professionals but all physicians should be aware of these unknowns. A physician assuming that he or she is aware of some knowledge but doesn’t really know is in fact performing guessing and then to proceed without being aware of one’s ignorance of some element of diagnosis or treatment can cause damage to the patient through possible subsequent error. Also without knowing what the doctor doesn’t know, the doctor can be delaying a consultation on the case by a physician whose medical knowledge is more complete in the particular information.
How does “not knowing what you don’t know” apply to the behavior of a patient? It does apply but in a different meaning and context than that of the physician but can be just as potentially harmful to the patient.
A person who is without symptoms and is unaware that they have tuberculosis may be made aware of the disease by skin tests and chest x-rays. If that person would agree to take these tests as an appropriate screening the person would then know and could be promptly treated. But what if a patient doesn’t want to know what is yet unknown to the patient? If a patient has trouble swallowing but fears that cancer is the cause, the patient may elect to delay going to the physician for a diagnosis, fearing the worst. By “not knowing” what is yet an unknown there may be some temporary comfort to the patient by the ignorance than being aware of the diagnosis of cancer, if present, but that would be delaying final diagnosis and treatment of whatever was causing the symptom.
I have written above that either the doctor or the patient “not knowing” can be harmful. Are there any reasons in either application of “not knowing what you don’t know” to the physician or to the patient could be accepted as something appropriate and an ethical “good”? Is ignorance ever bliss? ..Maurice.
posted by Maurice Bernstein, M.D. @ 2:21:00 PM
8 comments
8 Comments:
Sometimes a patient would elect to ignore the moment of his near death and this would be ethically accpetable.
When the patient consciously chooses to do so, he does it in order to enjoy the end of his days without having to counsciouly being aware of that stressful moment.
Oh, ignorance is often bliss. For example, it is the responsibility of the care providers to entertain a large number of horrible possibilities in response to common, overwhelmingly benign symptoms. Fortunately, the vast majority of these conditions can be ruled out, and the patient need not trouble with them.
Another example: caregivers are often frustrated, enraged or cynically amused by patients, the choices they make, and the things they say and do. Almost entirely, we keep the expression of those thoughts and feelings confined to ourselves and our colleagues. Again, patients are better off not knowing.
Should the questionable behavior of either party in a doctor-patient relationship be clearly expressed by one to the other party? Couldn't this be ethical and a benefit to both to have such concerns "out in the open"?
Or is the doctor-patient relationship too tenuous itself that in order to continue to maintain it and its therapeutic value, it is better to keep those questionable behavior observations by one about the other to ones self?
What do you think, Dr. Bernstein? I assume you have or have had a clinical practice? Do you share all of your emotional responses with the patient, including, say, frustration at slow talkers, stunned disbelief at the things people will feed their children, or rage at a drug-seeking system abuser who hits the ED once or twice a week for years on end with an endless list of pain complaints requiring narcotics?
I would share my concerns with the patient for two main reasons: 1) to open up the conversation to obtain more information regarding the behavior. ..and 2) which follows from #1..if such sharing would lead to therapy and some benefit for the patient.
If I don't find #2 is pertinent for the patient, I wouldn't share my emotions with the patient.. but when communicating with a colleague, I would then share and ventilate.
By the way, replace the word "would" with the word "did" since this has been my experience in practice. ..Maurice.
So it would seem that we agree that selective disclosure is sometimes in the interests of the patient.
Is "not knowing" ever in the interests of the physician? Hmmm. One could argue that it is. For example, it has been argued (in the scholarly vein in Stein's "Sources of Power" and in popular style by Gladwell in "Blink") that expert decision markers including physicians often ignore large bodies of information and evidence in order to reduce the situation to its essential features. Force a person to "know" things they do not want or need to know can result in worse decisions, not better. Like many young physicians, I've been cut off in mid-report by a senior attending who I have to believe wants all the relevant facts that will help them care for the patient -- but have learned via experience when more information equals less knowledge.
It gets even more basic. Studies of the interface between photoreceptors and the occipital lobe have shown that if a sensory input is not interesting enough, we literally do not perceive it to be there. Evolution keeps us ignorant of a large majority of the data arriving via our sense organs, to avoid overwhelming us with useless information, sensory "noise." Is not that ignorance blissful, or at least the alternative nightmarish?
A good physician will and does separate the wheat from the chaff but hopefully always keeping in mind that sometimes what appears like chaff is actually wheat. Attendings, as you have seen in the teaching situation, by their experience, may more easily separate the two with confidence. But they too are human and may make a mistake. ..Maurice.
A health problem my mother has took over a decade to diagnose, and "not knowing" wasn't bliss to her or the rest of my family. From the early eighties to the early nineties no doctor or specialist could figure out the cause of her serious symptoms, until finally she was diagnosed as having MS.
Apparently MS is a fairly new medical discovery, but there are already good methods of controlling it. In the eighties she couldn't walk well, talk well or even get out of bed sometimes. She was practically on her death bed when I and my six sibling were teenagers or younger. Now for the last ten years or so her life has turned around completely thanks to modern medicine (and great medical insurance). She isn't pain free but she is more healthy and happy now than she was twenty years ago.
We're all happy that she chose not to ignore her symptoms and searched for a specialist that could correctly diagnose her problem. If she had, she probably would have died fifteen or twenty years ago.
Post a Comment
<< Home