Tuesday, March 31, 2009

For Certain?

This morning I'm thinking about how we can know anything with certainty. In the Middle Ages philosophy reigned as the integrator of knowledge. I suppose it was an easier time or maybe a simpler one. From the perspective of the 21st century there was less to know or less that was known, and so philosophy could be relied on to put it all together.

The 20th century Roman Catholic theologian, Karl Rahner, argued the expansion of knowledge rendered us susceptible to what he called "gnosiological concupiscience," a tongue-tyer that essentially means none of us can know everything. I guess we always knew that but it's a convenient phrase to have on the tip of the tongue the next time cocktail party conversation lags and we're looking for a quick exit.

Seriously, though, Rahner was referring not only to the expansion of knowable things but the proliferation of pluralism that exists within specific fields of knowledge. We are no longer able to speak in terms of discrete disciplines like philosophy or science without specifying which one we mean. And this creates problems because none of us is sufficient to know enough about all of them to be able to integrate them in a unified field. Nevertheless, this is what we try to do.

Maybe it comes from discomfort with ambiguity. Maybe thinkers like Elton Trueblood are right after all, and humans have an inherent drive to establish or connect with a center of certitude. But like Archimedes, who said (more or less), "Give me a lever, fulcrum, and a firm place to stand, and I can move the earth," we want a reliable point from which we can begin.

We're all concerned about healthcare these days. Well, for years, or so the argument goes, doctors relied on their own clinical experience in decision-making rather than on the accumulation of scientific data. And the reason for this was, the absence of empirically-gathered data supporting one decision over another. We are now encouraged to rely on evidence that has been gathered experimentally to inform medical decisions. Based on the evidence, algorithms are developed to guide treatment. If A, do B, and follow B with C. If not B, do D. That kind of thing. It simplifies a lot.

The problem comes about when we're faced with situations that don't fit the algorithm and this is precisely what thinkers like Harvard's Jerome Groopman have pointed out. If you haven't read his marvelous book, What Doctors Think, I encourage you to do so before your next physical exam. It will open your eyes. Groopman points out how simple conditions like the common cold are very amenable to algorithms, but serious conditions tend to be far more complicated and frequently fail to fit within the neat confines of evidence-based medicine. When faced with this kind of situation, a person has to be able to think creatively and that means managing ambiguity.

There it is again, that pesky ambiguity. Seems like we can't escape it, can we? At every turn there's something that can't quite be reduced to A+B = C. So, where does our certainty come from, if not the absolute reliability of the scientific method? Maybe in the end we're forced to return to the core of individuality, that place where we encounter the depth dimension of life. And, of course, once there, we find philosophy and theology waiting for us. Pluralistic though they may be as well, at least they remind us that we can't escape being human after all.

It's something to think about.

Monday, March 30, 2009

Birthin' Babies

I have a friend who has a favorite line from Gone With the Wind: "Miss Scarlet, I don't know nothin' 'bout birthin' no babies." Up until this morning I could completely identify with the character of Prissy: all I knew was what I'd seen on ER. A one hour lab session with a professional mid-wife has changed all that.

Using plastic models, we learned how to use two fingers to measure the dilation of the cervix, feel the fontanelles (spaces between an infant's skull bones that enable the skull to alter its shape during childbirth), and determine whether an infant was coming out head first (normal presentation) or bottom first (breach presentation). I know, plastic models aren't exactly the real thing, but it's a start.

It's an amazing thing to see, even in a protected environment, how we enter the world. I overheard one student comment, tongue in cheek, "I'm never having children!" I can hardly say that I blame her because it's a herculean effort on the part of women. But the skin and muscles of a woman's pelvis are remarkably forgiving and elastic. They have to be in order to allow an infant to twist and turn as it makes its way through the birth canal.

One of my partners was a new, first-time father who'd seen all this up close and personally, and his broad smile throughout the lab was clear evidence that he was reliving the birth of his daughter. I couldn't help but remember the young doctor played by James MacArthur in the 1960s film, The Interns, who rather cockily felt obstetrics was beneath him -- until his first childbirth experience, that is. I think we're all looking forward to obstetrics next year after this morning.

The complications that can occur are beyond us at this point in our education. We're just trying to get the basics right: put your hands here, don't push to hard there, ask if the mother is comfortable, don't pull on the baby, and so forth. It's not rocket science; it's more about being considerate and skillful, knowing when to ask for help and when to let nature take its course. In that sense, it's about life and the lessons we all benefit from learning.

Saturday, March 28, 2009

Stepping Into the Fog

The fog is rolling

When I was a graduate student at Southern Methodist University I had the opportunity to study under Schubert M. Ogden. Although not exactly a household name, Ogden nevertheless was a brilliant and creative thinker who has since taken a very active retirement. In any case, I bring him up this morning because there's fog in the hayfield. When I woke up, it was only a tiny sliver along the treeline but in the past hour it's grown to the point that I almost feel like I'm living in a cloud bank.

Now what has fog got to do with Ogden? Well, it's like this. He once said that every human being lives on the premise of a basic faith that life is worth living. This is not religious faith as such, but simply the confidence that getting up in the morning is a worthwhile endeavor. He went on to suggest that this is, indeed, a faith decision because there really is no scientific or empirical evidence that living is preferable to the alternative.

This is very interesting. The newest buzzword in medicine is "evidence-based" and it refers to the idea that decisions should be based on the results of careful testing and the analysis of data. How could anyone determine that life was worth living based on empirical testing? Could we design a placebo-controlled double-blind clinical trial, such as is used in drug testing, to validate the premise? Forgive me if I sound ridiculous, but what would constitute a placebo? In drug testing, benign substances like a sugar pill are used as a comparison against the real medication. In a double-blind study neither the patient nor the tester knows who's gotten the medication and who's gotten the placebo. How can you fool someone into thinking life is worth living?

When it comes down to it, whether one likes the word "faith" or not, we go about our lives on the unspoken and, perhaps, unconscious notion that living is more meaningful than not. And that's one of the things that keeps us going. I can't see the hayfield for the fog bank, but that doesn't mean the hayfield is no longer there. It just means I can't trust my senses for valid evidence of its existence. If I want to walk out into the hayfield, I have to walk through the fog trusting my feet will find the ground.

Some would say I've simply made an assumption based on previous experience and faith has nothing to do with it. In point of fact, faith has everything to do with it. Faith has gotten a bad rap over the years and some would suggest it is both irrational and the activity of the uninformed. It is neither. Faith gathers and evaluates information and then acts on the basis of what is most persuasive. That is a rational process. We may not think about whether getting up in the morning is a good idea or not, but the fact that we do it means that at some point we decided it was better than the alternative. And that is a rational process, too.

Stepping out into the foggy hayfields of life may not always seem logical but that doesn't mean it's irrational. It just means a person has evaluated the information using criteria that is personally significant and decided on that basis. We may not always understand what drives a person and what motivates one might not motivate another. But however we live, sometime, somewhere, and in some way, we've decided that living is a pretty good idea. And that alone, is an act of faith.

(Creative Commons image by David Yu via Flickr)

Monday, March 23, 2009

Thirty Minutes

There's a lot to be said for short stories. In a few thousand words the bookends of a life are drawn toward the middle. We don't see all the details, but a key event or maybe just the daily pattern that reveals the core of personality. I'm old enough to remember when most television shows were a half-hour long and I was delighted with the advent of the sixty minute variety. Even better was the introduction of movies on TV -- yeah, I remember "Saturday Night at the Movies," thanks to the creativity of NBC's program directors.

I've always liked the longer story if given a choice. Thirty minutes was fine to whet my appetite but with the closing credits I felt a sense of loss. Surely there had to be more, especially if it was a good story. I think that's one reason why I like longer-term psychotherapy. Twelve sessions of skills instruction may suit the insurance industry's passion for profit margins (supported by the all-powerful "empirical" evidence), but there's more to care than simply managing repair.

In my time as a psychotherapist one of the most common things I heard from patients was, "I wish someone would just listen to me." And listening is something I tried to do regularly. Now, it's true, some people don't want to open their book and others aren't interested. Therapy is about patients and they determine its direction.

A good therapist is like the character of Virgil in Dante's Inferno. You remember how the tale goes, I'm sure. Dante is 35 and finds himself lost in a dark wood. Pursued or assailed by a leopard, lion, and wolf, he is near despair when he encounters the poet Virgil, who becomes his companion on a journey into the depths of hell. While it's true the Divine Comedy is a work of theology, taken metaphorically, it's also a description of the journey of persons from despair to meaning. When we find ourselves lost in a dark wood in the middle of this road we call life, we want a "Virgil" who's willing to go with us as far as we need to go to find our way out again.

Someone asked me once why I insisted on using the word "patient" instead of the more politically correct "client." Well, the reason is, patient means one who suffers and most of the people I've worked with were well-acquainted with suffering. It only seems right to recognize and respect that, you know?

We're all different: some people like the "half-hour show." Me, I like movies because thirty minutes is never enough.

Saturday, March 21, 2009

Thirty Years Ago

It won't be long before these Saturday mornings by the fire are a pleasant memory. Not because of anything bad -- far from it: spring is finally making its way into Southern Maine and it's more than welcome. The lilacs outside the front door are budding (it's time to trim them back a little) and the steadily melting snow reveals the remnants of last fall's leaves that still need to be raked and bagged.

I'm eager to see what this place looks like once the perennials start to appear. My predecessor was a gardener in another life and the farm shows it. The apple trees should be a sight to behold and there were wild turkeys in the field yesterday for the first time since November.

I was recently asked by another writer what it was like being an older medical student. Although it didn't occur to me at the time, spring out here in the country is part of that. This week is spring break and my younger colleagues have scattered to the four winds. One anticipates a week on a Florida beach (she assured me she'll be studying and I believe her -- proof of my naivete?) and others are visiting significant others and family. I'm looking forward to getting out into the forest and cutting next year's firewood.

What I mean is, instead of medical school being an interlude or a stage I have to pass through to get somewhere else, it's more a part of life itself. I don't think I would have had the same perspective thirty years ago. I was too busy imagining how life would be once I was free of the constraints of academia. I still think that way to a certain extent, but I also think more about the daily experience as life itself.

I told her (the writer I mentioned) that having a background gives a person a context in which to situate their medical education. We talk about having had a life but I think being older helps us realize medical school (or any endeavor undertaken outside the traditional calender) is life. Two years immersed in anatomy, embryology, pharmacology, and a dozen or so other "ologies" can seem interminable, to be sure, but it constitutes life at the time. Somehow that perspective makes it all easier. Not any less difficult, not any less demanding, but it helps create an attitude of acceptance that produces an occasional peacefulness that reduces the stress.

I say that today -- someone remind me of it the week after next when we're facing another exam. :-)

Tuesday, March 10, 2009

Snow Magic

I saw something extraordinary this morning. While taking the dog out for his morning "constitutional," we walked down our country lane that is lined with forest on both sides. The sun was shining through the trees and yesterday's fresh snow was falling in cascades from the tree tops some thirty or forty feet above. As it fell, it caught the sunlight and looked like columns of snow flakes and in some cases, there were shadows reflected onto the falling snow so it looked like a gentle spiral winding to the ground.

I ran back to the house, got my camera, and if any photos come out, I'll post one or two for you to see. It was quite incredible, standing there as snow fell, sometimes in small clumps as though the trees were throwing snowballs. You just never know what you're going to see -- what we often fail to see because we're too preoccupied. Perhaps today you could take a moment to see and be surprised.

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Saturday, March 7, 2009

Show Me The Way

Well, once again I've been AWOL from writing. The past three weeks have been awash with exams and whenever I've tried to write, the pressure of impending doom has disrupted my thinking and driven me back to the books.

Today I'm basking in the warmth of the first Sunday since fall that the temperature has risen above 50. That may not seem like much to those in warmer climates but in Maine, it's a heat wave. The sounds of water dripping from the roof and snow sliding off the barn are pleasant portents of spring that are truly welcome. My dog and I may actually walk today without bundling up.

For the most part, though, it still looks like winter. Snow covers the hayfield, I'm wearing flannel shirts (yes, from L.L. Bean -- who else?), and only a cock-eyed optimist would even think of taking the snow tires off the car before the end of April. So, it looks like we're in one of those transition periods where change is coming slowly.

I think American religious life is in a period of transition. For the past, oh I'd say thirty years, the trend toward fundamentalism has been a pretty dominant feature. I graduated from seminary in 1977 and the hottest topic of the day was what will the "End-Times" be like. The following year, students were arguing about the inerrancy of the Bible and by the mid-1990s the Southern Baptist Convention, the largest American Protestant denomination, had shifted to the right. The most recent Presidential election, however, showed signs of another shift, this time away from the extremes and back toward the middle.

Usually, during periods of social unrest and economic uncertainty, more conservative denominations flourish. But it seems people are hungry for more than the appearance of certainty, and in spite of the state of the economy report feeling more hopeful. What a paradox. Maybe we really are set on the brink of something new and vibrant in American life. Maybe for the first time in years, we're ready to stop looking for someone or something to blame and instead, looking to each other for solutions. I don't think we elected a President in the anticipation that he would be the agent of change. I think Americans are starting to feel the need to change themselves and they elected someone who can show them the way.
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