[HSF] Re: so does it "matter" how we think about medicine?

Sun Apr 6 17:44:32 EDT 2008

 (It has been a slow weekend on HSF or my computer is on the blink. Maybe some of you would be interested in one of my none Occam musings.)

So what really "matters" when we try to talk about our ideas in medicine? 
How do we talk (think) about what we do as surgeons? How do we intelligently describe biologic phenomena? What are the limitations, if any, in how we package or think about these ideas?

The mathematical or quantitative perspective is currently the dominate language and syntax for scientific methods and recommendations. What are the consequences of such language? We build a system that follows linear logic and calculative rules within which to decide "correct" behavior. We teach in this context (did you follow protocol, read the "relevant" articles, and pass the quiz?), practice in this context (did you follow the guide lines, have formal training, get credentials?), and are judged in this way (what is your mortality, how many do you do, did you meet you own guide line, doctor?). 

 Is there a consequence to limiting medical veracity to this language or format? 

There is in game theory a perfect player for this or any finite, tautological game. This game might be tic tac toe, or a more complex system, say Kirkland's textbook or the stock market. This Von Neumannian "player" can calculate the proper move and form player groups to maximize the best single value:  monetary, mortality, or etc. He may play at a very high (but finite) level including exploratory moves, random computed moves, or alliances. Since this player by definition is never incorrect in his numerical assessment, this player, or for us physician, would seem to be the paramount goal or ultimate status quo to be admired.

There are , however, formal requirements that impact the possible outcomes of this format or permissible world view.  One problem with this format is that all possible outcome and scenarios are extant INSIDE the system or tautology. This places certain constraints on this perfect player (which I will now call professor). Since the professor is "perfect", the interesting thing about this professor from the learning perspective is that while he plays perfectly it is with the level of "zero learning". As an analogy from chemical kinetics, this is "zero" order kinetics. Nothing is present to facilitate or accelerate the learning process. This perfect professor, who would be highly regarded for being "learnED", never wrong, and never sued, is unable to learn in the  common sense of trial and "error". Since the professor is incapable of error, he is forced to repeat the "proper" sequence  (from the tautologically or intrinsic perspective) every time, and
 therefore he can not "learn" to change the outcome. This system, if perfect, is a completely reductionist and calculable system in which learning might be better understood from a more typical detached or "outside" perspective not as perfect learning, but perfect adaptation. Learning seems to be missing. Should we call our training programs, both for residents and post graduates, adaptation programs or sensitivity programs? See the shift in gestalt from this mind set and language format?

Another problem with this perfect Neumannian player scenario is its mathematical behavioral characteristics. The outcomes tend toward chaos and volatility. It, the player or more correctly his pursuit of the highest single value, never reaches a sustained position or homeostasis. It is not reflective of a biological or human type of activity. It is probably for this reason that despite the rational desirability to be always correct in a system, that there are no useful models in game theory or professional activity for the perfect Neumannian player. For you aviation proponents, when events or behavior is non-stylized we turn off autopilot and let the real pilot come up with a solution.

On the other hand we may prefer to talk in terms more organic that feel more like the flow of phenomena we observe daily. We look at individual events for patterns, which are only sometimes numbers, that tie the events together as stories or processes. We look for context, sets, and systems that allow us to understand and change the flow of reality and outcomes. These are not determined in the main by quantities and calculations. Error is judged by time or other (outside?) perspective or value, or the perception of error at some point, is an essential part of new change or learning. At the least if no error, no need to challenge defined action or to change. Conversely action and its conscious thought may create flow changes that later may be judged tragic or heroic or wrong. A mental process extant in this system links error to learning as is destruction to creation in many ancient traditions. 

While we say that learning in this latter or creationist view point is to respond differently to the same stimulus or context at a later time, we are primarily talking about patterns not quantities, patterns that we build. No man can have sex with the same lover twice, at least for the first time. Thus we have to pick the relevant patterns in the flow of events. If we are inside an ideological set or tautology and wish to learn we must bring in something new: agent, timing, matrix or perspective. In doing so we also introduce and risk error. This world of creation and destruction we usually relegate to the prophets and poets, or perhaps, the politicians. But it is part of our world too. When we posit a mechanism, we destroy another. If this is too subtle, surely when we create one guide line or apply one therapy we exclude others.

We can not practice medicine or recommend to others to live in one of these worlds alone. Nor can we believe that we can live in only one while having the "goal" of being in the "error less" one. If we can not quantify and then test, we can be fooled by the repetitive patterns. If we can not be free to error and reorient our patterns, not only can we not create a new world, we are doomed to live endlessly in the present one.  These world views or formats are actually impossible to keep separate as they are bound together in our responses and perceptions, but it is easy to forget this tension and think we are immune from one or the other. The gap in reality that is found from either descriptive view alone is omnipresent. This gap or paradox is biologic and build into our ability to know and respond and think. Only in combining them are we truly human and truly free to change the past. and free to error in the process. This is our epistemological
 situation. We are dependent on our ability maintain the tension of the paradox we find in reality as we can know it. Our reality is a paradox. When we lose the paradox we lose the either the reality to measure our fate or to create a different outcome.

Paradox is reflected in the very words we use, at least the more primitive non latinized (non-reified) ones. Our words are embedded with this gap or paradox. What "matters"? This word "matter" means both the stuff and the meaning among the stuff. We fool ourselves, I think, if we chose to have only one perspective for truth. It certainly makes us look foolish. 

I say these things to you all because our thought leaders require the wisdom that comes with both experience and clarity. I say you ALL, because I trust none of us or group of us to preserve both our potential success and our potential error, and thereby our future. This is not another rant, but perhaps, a formal tool to help recognize before the fact when we may be in danger of losing our future.

For those in charge of setting policy, and we all are at some level, I will leave you with a quote from Gregory Bateson that sets out the above ideas in a concise manner:

     "Thus, in no system which shows mental characteristics can any part have unilateral control over the whole. In other words, the mental characteristics of the system are immanent, not in some part, but in the system as a whole."

tea

----- Original Message ----
From: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, March 15, 2008 8:46:49 AM
Subject: Re: [HSF] Rt thoracotomy MVR

Bravo Tohru!

Bob

-----Original Message-----
From: Tohru Asai <toruasai at belle.shiga-med.ac.jp>
To: OpenHeart-L at lists.hsforum.com
Sent: Sat, 15 Mar 2008 5:08 am
Subject: Re: [HSF] Rt thoracotomy MVR

Nand and Discussants!

I am interested in this long threads. And I found that this was the problem
of HSF. Why are you guys so eloquent even without seeing Nand's patient and
her CT scan. I don't care about who's repair rate, who's preferred approach
or generalized comments about each approach.

Is Rt. Thoracotomy really a right approach specifically to her by Nand? In
my mind, questions raised. How severe is her pectus? I experienced a case of
pectus for mitral repair a few years ago. Her lower sternal body is
literally 1 cm distance from vertebral body! Pectus is not simply sternal
and caltilage problem, but the whole mediastinum shifted abnormally. In his
case, he also mentioned "pectus was just filled with prosthesis", this means
the view from Rt. Thoracotomy must be quite different and difficult ( not
only far away but sternal body may be in the way!).Therefore, without
watching CT slice, we should not mention which approach is good or bad!

And if Nand is not always do rt. Thoracotomy, I am afraid that the
outcome...We certainly should take his experiences into consideration in
such a case, then we should comment properly.

Another question, which Ani mentioned too. I want to ask, Why did he want to
replace rather than repair the valve?  Nand should answer why he want to
choose replacement. Because of his experience? We all are not sure. If so,
probably he should ask an experienced surgeon to scrub in together, or send
the patient to a surgeon who is good at mitral repair and good at
non-sternotomy approaches ( Lt. and/or rt.). Although I am not sure how
difficult to perform sternotomy for her.

Nand! Forget about asking tips. Please upload CT scan. Then we can discuss
more realistic strategy and tips you want!
-- 
Tohru Asai
Shiga University of Medical Science
Otsu, Japan

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