How Did You Know?
“How did you know?” This question was asked of me by the young ER doctor who had called earlier that morning. He had seen a patient who presented sick and confused to the point where he could not give a history. A laboratory panel had returned with a lot of abnormal findings, and he was calling for help. Based on what he told me, I quickly suggested he look in a different direction and do a CT scan of the patient’s abdomen. The study yielded the diagnosis and he wanted to know how I had known to go looking there, when none of the laboratory tests seemed to be pointing that way. I really did not know why I had “known” that was the direction to go and I could not really tell him at that point why my clinical intuition had suggested the answer. When I got to the ER to look at the patient for myself one of the older ER doctors told me he had been asked the same question. The ER doctor’s answer was simpler. “That’s what Dr. Wright does.” While gratifying, Dr. Jerome Groopman, who writes on how doctors make diagnoses, would point out that I am only relating a success—not all the failures. One of the most common errors is to lock into a diagnosis too early and then fail to reconsider when conflicting data become available. So how did I know?
I have recently become aware of the writings of Michael Oakeshott on knowledge, first published in 1947. He made a distinction between technical and practical knowledge.
Every science, every art, every practical activity requiring skill of any sort, indeed every human activity whatsoever, involves knowledge. And universally, this knowledge is of two sorts, both of which are always involved in any actual activity…The first sort of knowledge I will call technical knowledge or knowledge of technique…its chief characteristic is that it is susceptible of precise formulation…The second sort of knowledge I will call practical, because it exists only in use, is not reflective and (unlike technique) cannot be formulated in rules. This does not mean, however, that it is an esoteric knowledge. It means only that the method by which it is shared and becomes common knowledge is not the method of formulated doctrine.
Indeed, as in all arts which have men as their plastic material, arts such as medicine, industrial management, diplomacy, and the art of military command, the knowledge…is pre-eminently of this dual character. Nor, in these arts, is it correct to say that whereas technique will tell a man (for example a doctor) what to do, it is practice that tells him how to do it—the “bedside manner,” the appreciation of the individual with whom he has to deal. Even in the what, and above all in diagnosis, there lies already this dualism of technique and practice: there is no knowledge which is not “know how.”
A couple of days later I was at a meeting with a number of physicians, hospital administrators, and a couple of the hospital trustees, when the CFO made a presentation on the problem of recognizing and capturing “savings” from clinical performance improvement projects. He was quite explicit in saying that there was no report or line item that could be consulted for determining savings, and then went into a discussion about how they try to cope with the need for being able to make these determinations. I was struck when he noted that “The EMR makes it possible for us to capture tons of clinical data that we did not have before, and we should be able to link it to the tons of financial data we already have.” I suggest the EMR gives tons of data, but very little information, just as the financial data does not give much information about the question at hand—how much money does a clinical performance improvement project save?
Of course, the CFO is not a clinician, so the meaning of the data is not something he should be expected to grasp. But the physicians in the room, who are not financial people, were having trouble grasping the meaning of his statements about the difficulties in spelling out where the dollars are and where they go. In a very real sense, the doctors were asking: “How do you know?”
Oakeshott was interested in what he called the “rationalist” impulse that he saw pervading politics and everyday life. He observed:
Now as I understand it, Rationalism is the assertion that what I have called practical knowledge is not knowledge at all, the assertion that, properly speaking, there is no knowledge which is not technical knowledge. The Rationalist holds that the only element of knowledge involved in any human activity is technical knowledge, and what I call practical knowledge is really only a sort of nescience, which would be negligible if it were not positively mischievous. The sovereignty of “reason” for the Rationalist, means the sovereignty of technique.
The heart of the matter is the pre-occupation of the Rationalist with certainty. Technique and certainty are, for him, inseparably joined because certain knowledge is, for him, knowledge which does not have to look beyond itself for certainty: knowledge that is, which not only ends with certainty, but begins with certainty and is certain throughout. And this is precisely what technical knowledge seems to be.
This desire for certainty leads back to the case I presented at the start. What was confusing the ER doctor was the apparent certainty of the lab as opposed to the apparent uncertainty of the clinical history and physical exam. And what was confusing to the doctors was the apparent certainty of financial data and the apparent uncertainty as to why the CFO could not say how much money was saved from various clinical projects. This desire for certainty, and the illusory nature of certainty once one has both technical and practical knowledge, is, I suspect, one of those rocks on which health care reform is likely to founder. The financial folks want certainty from the clinicians that cannot be delivered in the same way the doctors at the meeting wanted answers the financial folks could not deliver.
So what are we to do? I think successful medical organizations will find that they have to respect the practical knowledge possessed by both their clinical and administrative staffs, and will, in the end, have to find ways to incorporate their collective intuition. The question really is not “how do you know?” It is really “who do you trust?”
11 July 2014
 Oakeshott, Michael. Rationalism in Politics and Other Essays. (Indianapolis, Liberty Fund, 1991; orig. publ. London, Methuen & Co., 1962.) The essay “Rationalism in Politics” first appeared in Cambridge Journal, Vol. I, 1947. Accessed 21 June 2014 at https://faculty.byuh.edu/troysmith/BYUH/Classes/Philosophy/Oakeshott%20-%20Rationalism%20as%20Politics.pdf.
 Oakeshott, pp. 12-14.
 Oakeshott, pp. 15-16.
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