Our prehistoric ancestors came out from the forests of a drying Africa to embark on their remarkable biological and cultural journey towards a new species, so in a sense we are the children of the forests. They gave us shelter, medicine, shade, food and fuel in great abundance … the brilliance with which trees have evolved and adapted over the last 200 million years [teach us] about survival and defence, partnership and sustainability, conservation and the endless creative possibilities of nature.
Max Adams, in The Wisdom of Trees
The ‘Ancient Oak’ of James Ward’s beautiful painting could be 500 years old, perhaps older. Surely, if a tree can be wise, this one will be. But Max Adams goes on to write:
“This book is calledThe Wisdom of Trees not because trees are wise, but because we would be wise to learn from them.”
So we must learn our wisdom from wherever lessons can be had, including trees. But we remember…
Life offers its wisdom generously. Everything teaches. Not everyone learns.
Rachel Naomi Remen
Clinical Judgment and the Protocol
Creativity is knowing what to do when the rules run out, or there are no rules in the first place.
The Story of Margaret
This story was told by a GP colleague about a patient she was currently seeing. This is a transcript from audio recording; name and elements of the story were changed to protect anonymity.
“I was just thinking of one of my patients. She has purely fatigue and she’s convinced it’s something in her mouth. So it’s very difficult. Complaints of fatigue are so common. She’s an incredible woman; she’s very high-flying, very gifted at what she does, but she has these episodes of profound tiredness where she can’t do her music – she plays the piano – and she can’t do her composition. She has started to link this with an infection that followed dental treatment and has seen Max-Facs [maxillo-facial surgeon] on numerous occasions and has had surgery which hasn’t really helped and although the pattern recognition for the stress side of things is quite common, the specific details of the surgery and her thoughts on it is unique and quite difficult, because she is quite convinced that it’s all linked with this infection.
She is very, very intelligent and comes in with everything written on an iPad with mind maps, digitally generated. You have to understand where she is coming from. She is a computer programmer. She is very used to problems being presented to her and I imagine being able to think logically. She is very, very logical – Oxford graduate – and having something outside her control, perhaps she can’t immediately fix, but she’s open to the fact it could be in her head. It’s tricky because she keeps going back to wanting more and more surgery, private referrals to Max-Facs.”
Margaret’s problems are uniquely hers. But any general practitioner will recognise her story. The GP colleague telling the story later called it a ‘flavour’, an intriguing metaphor. She immediately quoted another patient with a similar flavour. This ‘pattern recognition’ is a variant of the commonality that defines a diagnosis. But a useful medical diagnosis is one that provides clues about what to do next. We could say that Margaret has the diagnosis of ‘Somatoform disorder’, but this is little more than fancy words to describe the symptoms and is unlikely to help her. Holding this uncertainty and finding the opportunities in it requires imagination, skill, experience and time, with the patient as a partner on this journey. You could call this approach, Wise. If the ancient tree above were an ageing doctor, somehow we could imagine he or she would know how to do this.
Guidelines, protocols and checklists
Modern health systems are awash with algorithms, guidelines and protocols that may give us the feeling that we know what to do but they risk overdiagnosis and overtreatment. Of course, they have their place, especially for complex procedures where the inclusion of every detail is important. Atul Gawande promotes checklists for this. But this is not for Margaret or many other patients, particularly those with multiple long term conditions. Perhaps for them the protocol or checklist could become an aide-memoire, a recipe to fall back on, but will always lack the creativity of the chef-de-cuisine.
The wise way forward is based on a human relationship of trust and mutual respect as part of a holistic view of the person and the challenges. However, the ‘system’ is not geared for these supposedly unreliable and unquantifiable manifestations of humans in conversation. Worse still, the Evidence Based Medicine (EBM) movement, upon which the system rests, is described as ‘a movement in crisis’ for five reasons: (1) EBM’s ‘quality mark’ misappropriated by vested interests; (2) volume of evidence (especially clinical guidelines) is unmanageable; (3) statistically significant benefits may be marginal in clinical practice; (4) inflexible rules and technology-driven prompts produce management-driven rather than patient-centred care; (5) evidence based guidelines do not work well with multiple illnesses – ‘multiple morbidity’ – now the great majority of patients with long term conditions. This is made clear in a report from the Royal College of General Practitioners in 2016: short version; full version. The main risk to patients like Margaret with medically unexplained physical symptoms (MUPS) is one of bouncing around the health service, consuming resources and becoming entrenched in their patienthood.
The Quest for Certainty
Medical rules have been invented to smooth out the real world; but the world won’t have it. Nature is untidy and unpredictable. We must learn to enjoy uncertainty and enjoy using our wonderful faculties of judgment. A physician and patient persisting in a quest for certainty, reaching for multiple tests and multiple specialists and every test and every specialist risks finding a spurious flaw that leads down another and another and another avenue of false hope, and the space for interpretation shrinks away until the tangle cannot be escaped.
Don’t you see that the whole aim of Newspeak is to narrow the range of thought? In the end we shall make thoughtcrime literally impossible, because there will be no words in which to express it. Every concept that can ever be needed will be expressed by exactly one word, with its meaning rigidly defined and all its subsidiary meanings rubbed out and forgotten. Already … we’re not far from that point … Every year fewer and fewer words, and the range of consciousness always a little smaller…
As Orwell wrote, we are already on our way to smaller consciousness, to a language unable to grasp or imagine the complexity of the human condition. The escape, whilst there is still time, is judgment. In an inspiring article entitled The place of judgment in medicine from 1994, James McCormick paints a picture of the ‘doctor’s doctor’ whose curriculum vitae was ‘not outstanding’ but who was valued by his colleagues, ‘not because of his learning and his skill, but because his actions were tempered by wise judgment’. It is the very quietness of this achievement that should make us take notice.
The water in a vessel is sparkling, the water in the sea is dark.The small truth has words which are clear; the great truth has great silence
Rabindraneth Tagore: Stray Birds
Knowledge is proud that he knows so much; wisdom is humble that he knows no more.
William Cowper: The Task
It is a more recent thinker that informs much of McCormick’s article: Theodore Fox, and in his famous lecture, The Purposes of Medicine, (1965) he included this sentence:
“Doctors, like other people are ‘hot for certainties in this our life’, and, like other people, they would welcome any commandment that could not be questioned and thus absolved them from painful decision.”
“Doctors, by a person’s decision to seek advice, are given a mandate to exercise judgment on that patient’s behalf. This, at least to some extent, flies against the popular movement to grant patients full autonomy and the right to share… There is a place for rules in medicine, rules which can only be broken in exceptional circumstances and which if ignored carry the possibility of grave harm… For the most part good rules are concerned with potentially life threatening situations… In a sense these are simple situations in which there can be no difference of opinion about the immediate necessities. Such simple situations are the exception and the notion that rules can be devised for medicine as a whole carries the danger of great harm.”The place of judgment in medicine by James McCormick
We don’t receive wisdom; we must discover it for ourselves after a journey that no one can take for us or spare us.
And we don’t have to wait until we are as old as James Ward’s Ancient Oak. We are presented with opportunities every day of our life.
No one ever told us we had to study our lives,make of our lives a study, as if learning natural historyor music, that we should begin with the simple exercises first and slowly go on tryingthe hard ones, practising till strengthand accuracy became one with the daringto leap into transcendence, take a chanceof breaking down the wild arpeggioor faulting the full sentence of the fugue.– And in fact we can’t live like that: we take oneverything at once before we’ve even begunto read or mark time, we’re forced to beginin the midst of the hard movement,the one already sounding as we are born.
Here are two young GP colleagues talking about wisdom:
Penny: I just think as a job we are relying an awful lot on our intuition and decision making that is not necessarily based on something that we have learnt in a book. As each day goes on I realise that actually … some things are just medical …
Eleanor: … and you can just move through …
Penny: … [ but many things are not, so ] it’s not a job that somebody who is just medically-minded could probably be satisfied with … and want to carry on doing. [later] They’re asking for advice, but it doesn’t come from textbooks whatever … [hesitantly] … it comes from … the advice they are seeking … I try to support and give, but often I can hear my dad talking, or my sister … I don’t think that’s a bad thing, so long as it’s not a prejudiced view … we learn wisdom from others.
So how can we help this learning of wisdom and the judgment enabled by it? We can do this by being self-caring and balanced in the way we live; so we are as much a member of the human community as we are the medical community.
The need to relate the practice of medicine to the rest of the human world is unavoidable … When medicine is the only system of thought available to a doctor, when all available time and energy are spent on medicine, when the doctor is only an expert technical specialist then how can he or she become aware of the incompleteness and imperfection of medicine? Medicine must be seen in context, practised with wisdom.
This challenge balancing is not new. The Classical Greek philosophers and poets were very well aware of the need for wisdom to combine both the hard technical and the soft feeling parts of humanity. Aristotle wrote that wisdom requires both Sophia and Phronesis. Sophia is theoretical knowledge (episteme) that is logically built up, teachable and sometimes equated to science. Phronesis is practical wisdom, related both to virtue and practical details. It includes techne, meaning a craft. So in Classical Greece, wisdom was a combination of knowledge (including universal truths) and practical, virtuous know-how.
This sort of journey towards wisdom and the balancing of very different kinds of knowing is beautifully described in Matthew Crawford’s book: The Case for Working with your Hands . Crawford was educated in physics, political philosophy and motorcycle engineering as a practical artform. This book is wonderfully inspiring. He is a testament to breadth of being and being Wise before being old!