Eliot’s triad: information, knowledge, and wisdom in medicine
Where is the Wisdom we have lost in Knowledge?
Where is the Knowledge we have lost in Information?
|Photography by Les Taylor|
I first saw these well-known lines by T. S. Eliot1 inscribed as a motto on the flyleaf of a Greek textbook on internal medicine. I was a student then, and almost a quarter of a century passed before I pondered on their significance. We live in a world that worships information, and there is virtually no limit in our quest for broader and speedier access to it. In such a setting a critical approach to information would probably appear completely out of place, even bordering on heresy. Yet in medicine we need to view information in the right context and perspective. What is its relation to knowledge and wisdom? Can overgrowth of the one lead to atrophy of the other(s)? To answer these questions, let us first consider these three concepts.
Information can be defined as ‘point knowledge’. Its ‘point’ character refers not so much to its size as to its ‘time fix’ (when is it provided) and ‘shelf life’ (the lifespan of its validity). Thus today’s information may eventually prove to have been premature, wrong, or even deceitful. Vital to medicine, information adds to knowledge and promotes science. But it also has its negative side, and may even prove dangerous. ‘Point knowledge’ is the staple food of the mass media, and when it comes from medicine, it creates a wide stir that may affect the lives of many people. Quite often medical news attain publicity at the information stage, before they become established knowledge, and this may lead the lay public to dangerous action, such as in 1988 when, the New England Journal of Medicine published the results of a large study in 22,000 doctors showing the efficacy of aspirin in preventing myocardial infarction.2,3 As A.S. Relman, then editor of the Journal, wrote, “Judging from newspaper reports of rapidly emptying drugstore shelves, millions of people must have rushed to medicate themselves without the benefit of medical advice—a potentially dangerous practice.”3
Knowledge, unlike point information, is the synthesis of several points on a particular subject in an attempt to form a logical whole. It may be derived from an isolated report, a prospective study, or even a randomized controlled trial, but must be independently repeated and verified before it becomes established medical knowledge.
Undergraduate, but also to a large extent postgraduate medical teaching, tends to be based on knowledge that has a finite lifespan and is rapidly revised. It is a well known dictum, attributed to various medical deans, that “Half of what we have taught you [our medical students] will be proved wrong within the next five years; the trouble is, we don’t know which half’.” This is the reason why specific medical topics are regularly reviewed in medical journals, ‘state-of-the art’ or ‘current opinion’ lectures, or presented in the form of guidelines or consensus statements.
Wisdom is the critical evaluation of knowledge and the ability to select and apply it using not only scientific but also moral, ethical, social, and financial criteria. Wisdom goes beyond the narrow confines of science. It incorporates personal experience, judgment, discretion and discrimination, and even compassion and clinical instinct. Sagacity is another word for this kind of wisdom. It takes wisdom (knowledge plus experience plus clinical judgment) to select those patients for whom the benefits of a certain treatment will outweigh its side effects. Such wisdom forms the basis of the art of medicine.
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Can knowledge be eclipsed by information? It appears that this phenomenon is anything but rare, and it may be becoming even more common. The overgrowth of information in our era and its broad dispersal by digital technology “has magnified the problem of unwanted information, and busy clinicians are now caught in an information paradox—overwhelmed with information but unable to find the knowledge they need when they need it,” in the succinct words of J. A. Muir Gray.4 The same author states that “those who complain about information overload are the same people who complain about never being adequately informed.” These antitheses underscore the confusion between information and knowledge.
The abundance of information may lead to a deficit in knowledge when there is a lack of (or inability to utilize) synthesis and judgment in the selection of such information. Thus the widespread availability of the Internet has provided the broad public with virtually unlimited access to medical (and other) information, but at the same time it has largely eliminated all “safety valves” of expert review.5 It may also result in the public being carried away by the sensational and not wait for the critical evaluation of information (or even knowledge). The mass media are not indifferent to this phenomenon. A study in the USA concluded that “news-media stories about medications may include inadequate or incomplete information about the benefits, risks, and costs of the drugs as well as the financial ties between study groups or experts and pharmaceutical manufacturers.”6
The pharmaceutical industry often uses this tendency and bases its promotional campaigns on partial truths to justify the introduction of newer (and inevitably costlier) drugs. In the words of P. Gøtzsche, “it is profitable to convince clinicians that small differences between similar drugs are significant.”7 It is well known that studies showing positive results get published more easily than those with negative results (publication bias),8 and this often leads to one-sided education of medical practitioners. This bias may also crop into meta-analyses; one study detected it in almost half of the meta-analyses examined, although it affected the final outcome in less than 10 percent.9 It takes wider knowledge and a critical stance towards the glossy paper in order to see the forest and not just the isolated trees that are selectively presented there. Every therapeutic novelty advertised should not automatically lead to alteration of our traditional practice if there is no sufficient reason. William Walker, one of my clinical mentors in Britain, used to say with some pride as he approached retirement: “In my career as consultant physician I saw many drugs appear in the medical market and disappear again, which I never prescribed.”
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Can the tree of medical wisdom be lost in the tropical jungle of knowledge? Unfortunately this may happen when in the eyes of the doctor-scientist, the experiment or the randomized study takes priority over human suffering; when patients become simply ‘material’ that will lead to a thesis, the next poster in a congress, a research grant, or academic promotion; in a word, when physicians forget Socrates who stated that “all knowledge, when separated from justice and virtue, is seen to be cunning and not wisdom” (Plato: Menexenus 247a).
Contributing to this loss is an unbalanced education that immerses doctors in medicine to the exclusion of the humanities, literature, theology, philosophy, ethics, and the arts. Given the demands of medical work, it is hard for physicians to set aside time and energy for such ‘secondary’ pursuits. The result is an asymmetrical hypertrophy of specialist knowledge without the parallel development of general education and broader critical function. One of the aims of medical education should be to teach doctors how to select out those essential morsels of information that will complement or revise existing knowledge. This requires an investment of time and effort, which can only lead to greater wisdom.
- Eliot TS. Chorus from The Rock (1934). In: Eliot T. S. Selected Poems. London, Faber & Faber, 1954.
- The Steering Committee of the Physicians’ Health Study Research Group. Preliminary report: findings from the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med 1988; 318(4): 262-4.
- Relman AS. Reporting the aspirin study: the Journal and the media. N Engl J Med 1988; 318(14): 918-20.
- Gray JAM. Where’s the chief knowledge officer? BMJ 1998; 317(7162): 832.
- HON Code of Conduct. At: www.hon.ch. Accessed February 7, 2013.
- Moynihan R, Bero L, Ross-Degnan D, et al. Coverage by the news media of the benefits and risks of medications. N Engl J Med 2000; 342(22):1645-50.
- Gøtzsche PC. Why we need a broad prespective on meta-analysis. It may be crucially important for patients. BMJ 2000; 321(7261): 585-6.
- Stern JM, Simes RJ. Publication bias: evidence of delayed publication in a cohort study of clinical research projects. BMJ 1997; 315(7109): 640-5.
- Sutton AJ, Duval SJ, Tweedie RL, Abrams KR, Jones DR. Empirical assessment of effect of publication bias on meta-analyses. BMJ 2000; 320(7249): 1574-7.
, MD, MRCP(UK), DipPallMed, is a practicing pulmonologist in Thessaloniki, Greece. He received his MD degree from the Aristotle University of Thessaloniki Medical School in 1981. He trained in internal medicine in Greece and subsequently in the United Kingdom, and specialized in pulmonary medicine. He also holds a postgraduate diploma in palliative medicine from the University of Cardiff, Wales, United Kingdom. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, Greece. He is editor of Iatrika Themata, the journal of the Thessaloniki Medical Association.
Highlighted in Frontispiece Spring 2014 – Volume 6, Issue 2