Abstract

Medicine in the world is at a crossroads. There are several factors for this. Complexity is a major factor. The sheer amount of medical data generated daily is staggering. The practice of medicine /surgery has seen massive changes. It like other major institutions has developed similar business plans i.e. control at the top, whose composition may vary. Departments below are tasked with actions, to ultimately contribute to the goals of the company. There is little incentive to question, and in fact, so doing may risk sanctions. This model is based on certainty, whereas history throughout thousands of years has shown the utility of “doubt.” This paper recounts philosophical discourse through millennia, concerning doubt to successfully navigate the real world. I hope, this paper stimulates multiple stakeholders to analyze and deal with doubt for the betterment of all.

Keywords:Health care; Medicine; Surgery

Introduction

Medicine as other large, complex organizations are continuously dealing with the massive changes brought on by the new Information Age. I previously discussed this issue [1,2]. Instant access to massive amounts of data [knowledge] has many advantages. Unfortunately, there are several serious disadvantages. Organizations have taken steps to deal with these issues, internally and externally. Human resource departments are important. Education of employees on multiple fronts from employee conduct, to specialized knowledge of the enterprise [3,4]. They also need familiarity of the rules and functions of government agencies and private entities i.e. specialty boards, facility certification requirements etc. [5]. These are useful suggestions. I posit that a root cause of organizational failure is the inability of stakeholders to ask ‘why’, and cast ‘doubt ‘.

Doubt has been a major concern of philosophers for over 2 1/2 millennia. Socrates, Plato and Aristotle discuss it [6-8]. The paradox they realized, is that the more you know, the more you don’t know. However, at times wisdom [ true knowledge ] accrues in a few, allowing insight to a better way. It must be noted that Aristotle’s position are more nuanced than his predecessors, since his philosophical views are heavily influenced by human obser vation. He arguably, is the first practical philosopher in history. Discourse over the subsequent centuries was conducted by thinkers influences by the time they lived. Saint Augustine [9] at the dawn of Christianity, when it became the official religion of the Roman Empire; Saint Thomas Aquinas [10] during the medieval times [age of scholasticism ]; Descartes [11] and Spinoza[12] at the beginning of the empirical revolution. Kant [13] during the first Industrial Revolution ; and more recently, Popper [14] and Russell [15] considers this problem in modern times. All this evidence is supportive my thesis. Important figures have also stated their doubts at crucial times in the world history, and how they dealt with these phenomena. This list is vast, but for purposes of this paper several are mentioned. Eisenhower, Lincoln and JFK wrestled with doubt [16-18].

Michelangelo and DaVinci, both had lifelong doubts [19,20]. Mother Teresa, despite working under difficult conditions for decades, questioned her faith [21]. Famed novelists John Steinbeck [22] and Edith Wharton [23], who are still applauded for their works, on occasion questioned the quality of their works. Excess of self-doubt hinders a person’s life and leads to ‘imposter syndrome’. This is an issue for many high achieving students. The University of Oxford discusses its genesis, potential seriousness, and treatment options [24]. An important point is that many psychological states from self- doubt to anxiety can be helpful at a low intensity, while at higher level it can become pathological [ I urge readers to further explore this concept, if [interested ].

Doubt in the 21^st century

A 2022 study by Brady and Kent cites a 50 year pattern of increased doubt in American society supported by cited studies [25]. They note initial factors of financial instability, mass worldwide population movements from the third world, conflicts world wide, and the apparent inability of governments to improve these issues. A final important point of theirs is that governments need legitimacy to inspire trust to minimize scepticism. A Pew article furthers the discussion, and offers strategies for improvement of this multi-faceted problem [26]. Patients, now routinely surf the internet prior to seeing their doctor, and often question her about subsequent testing and treatment. Reasonable doubt is a positive in this case, as discussed above. It also allows the doctor, to consider these issues. This is beneficial in the doctor/patient relationship by allowing positive changes in the treatment plan. The doctor projects concern, and a willingness to seek, newer approaches, proven by data to be safe and effective for her patient.

Silos of expertise

Paul Enger, a management consultant, famously used the term “ silos” of knowledge and skill, when trying to understand failures within a company’s business plan [27]. He used the metaphor of silos of yore, which separately stored wheat and corn. Specialists’ knowledge was likewise separated in their departments. This limits communication between departments. This presumably impairs efficiency and productivity. Others concur [28,29], while Dr G Miller from University of Glasgow first raised the possibility that using ‘silo’ theory in all cases may be counter- productive. It may not apply to all situations [30]. He further states that in certain situations, a company needs to merge the skills of all, instead of separating them. Kramick [31] and Edward O Wilson [32] take this idea further. They propose de-emphasizing specific disciplines, and encourage knowledge shared by all to attain a common goal. Their view is that principles from different disciplines, need to be linked together to form a comprehensive theory for action. They posit that during the current scientific revolution, there is increasing connections between disciplines. Thus, a ‘consilience’ is occurring. This linkage is more important in their view, than the further development of distinct disciplines.

I have reasonable doubts, concerning the wholesale change of specialized education i.e. the professional [law, medicine, business etc] to improve consilience. I am not convinced by the strong support of other prominent voices [33,34]. One, this movement may only be a fad. Two, professional training molds its members personality, knowledge and skills particular to the profession. This is invaluable in my opinion. Most professions have an arc of what is be done and how. Professional behavior and balancing professional commitments with personal, including family and health maintenance are crucial. Mentors, who have gone through it are essential. I think the cultures of the major professions, while sharing some common features do have some important differences. Law, medical and engineering schools require different academic skills. Personalities are slowly molded over the years, so what was once seen as strange i.e. waking up at 5:30 am and working 15 hrs becomes a habit, which is needed for that profession. This may be a foreign for some in other professions. This is related to the next point. Three, this approach may, but not necessarily ‘water down’ the curriculum, which in turn damages specialized competence. This would impair specialty tasks i.e. how to conduct an operation, argue a case in court or build a bridge ? Professional skills are honed by discipline, patience, knowledge and mentorship. These training methods have been developed over generations, sometimes over millennia.

My current observation of patient care

I have lived in the northern suburbs of Atlanta for 10 years. I was in a private ENT group for several years practicing basic ENT and outpatient plastic surgery. I have been under the care of a primary care MD. I witnessed how corporate control emphasizes volume and amount of charges. Hospitals besides patient care, seem concerned ensuring patients use many of its services. Often the further care, you receive is dependent on who you first saw. Some problems i.e. allergies, pains [throat, face, nose etc. are seen by multiple specialities in multiple arenas. Bothfactors are important. If you have neck pain for example, a neurologist / neurosurgeon has one approach, a pain specialist another, while a rheumatologist has a totally different approach. Unfortunately, MD skills such as history /physical, and formulation of subsequent care are minimized. Tests, and consults which may get the answers, are the standard course in many cases. This often leads to multiple appointments, in multiple locations over several weeks. Patients unsure of their condition, some- times get anxious, frustrated and sceptical. Adjusting to the digital revolution, will take years in my view to find the best balance. It will consist of staying current in all sectors from software advances to regulatory changes. Advantages of the system, which improve the efficiency, , and availability, without sacrificing factors that affect patient’s satisfaction, are the goal.

On the other hand, disadvantages especially those perceived as dehumanizing, need to be minimized. Also, organizations need to realize that overuse of this technology is damaging to a patient’s care and experience. I think that now as before, medicine is a profession to treat the sick. Those involved must be rigorously trained. The skill sets needed to practice, require lifelong learning. Doctors instill trust by being and appearing competent and caring. Maintaining calmness and professional demeanor is essential. A person of honor, who manifests these and other virtues especially faith, hope, charity, honesty and candor has the tools necessary to navigate a more successful career and personal life. Life is uncertain and at times it fills everyone with doubts. Courage is needed to confront these problems, and do our best to remedy what we can and ask others for help when needed. Finally, this paper illustrates the increasing need in health care for philosophical input to better understand current issues of concern, and anticipate future dilemmas. These may be the result of past decisions, or further improvements in science which create novel, previously unimagined situations. This further supports this thesis that doubt, causes one to ask ‘why’ is essential to improving health care and other sectors of our culture. There seem to be two options, for having philosophical input in organizations. One option is an inhouse department. I doubt the long term viability of this option. Companies have been observed not adequately supporting with money and needed infrastructure, departments not seen as essential, during difficult fiscal times. It is more likely the supported evidence presented here-in, an outside philosophy group with the requisite knowledge, flexibility and ability to tackle these issues is a better choice.

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