Annals of Royal July






The expansion of scientific enterprise has generated a vast accumulation of documented facts. An individual is no longer able to read and comprehend all that has been written, even within a limited field of interest. It is easy to be overwhelmed by the size of the archives and so disregard our fundamental ignorance in many subjects. Medical training at all levels concentrates our minds on known and accepted facts. In a practical profession devoted to preventing, diagnosing, and treating illness this is appropriate. Too great an emphasis on uncertainties would breed ineffectual doctors, unable to make firm decisions or inspire confidence in their patients. Moreover, students retain facts best when they are well understoood and can be linked together within a framework. In contrast, isolated, incomprehensible, and apparently irrelevant facts are difficult to retain. As a result, favoured subjects for lectures and textbook chapters are tidy entities that can be presented as a pattern of firmly understood facts. Incongruous, unlinked facts tend to be excluded or underrated. For easy comprehension when true explanations cannot be provided, hypotheses are often introduced, even if they have no basis of supporting facts. If no hypothesis can be manufactured teleological explanations may be given. When the cause of a disease is quite unknown terms such as 'primary', 'idiopathic', or 'essential' are applied. They have the dubious merit of sounding impressive when used in front of patients, but the


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meaninglessness of the terms is soon forgotten. Formal examinations exert a powerful influence upon teachers, and writers, to present orthodox views. In order to be fair, examination questions must be tailored to test areas of knowledge on which there is some concordance. A sensible candidate organizes his facts into neat 'packets' under suitable headings and is ready to quote the appropriate teacher or textbook if he is questioned. He wisely has available the current hypothesis or teleological explanation for awkward facts that do not fit into the framework. Because the field of knowledge learned for, and tested in, examinations is limited in scope the subject appears artificially well founded. In fact vast areas of ignorance are glossed over. Every practitioner frequently meets clinical situations that have not been covered in his examination curriculum. It might be thought that in the field of research the awareness of ignorance is sharper, but this is not so. Scientific endeavour is focused on small areas of growth as new techniques are exploited, while those fields in which research is considered unprofitable are neglected. The formalized structure of scientific reports sometimes prevents uncertainties from being exposed. At present it is difficult to publish a single idea, or anomalous finding, or observation, unless it forms part of an investigation. The practice of reporting only 'relevant' results may obscure an important anomaly. The discussion is frequently limited to arguments that support the author's

contentions and those opposing arguments that can be demolished. If the author does report anomalous findings he is expected to provide an explanation for them. This leads to the proliferation of hypotheses which, if not soon disproved, gain acceptance. Harvey wrote, 'Doctrine once sown strike deeply its roots, and respect for antiquity influences all men'. Patently false views are thereafter often reproduced because no one has specifically carried out an investigation to disprove them. Hypotheses are usually selected because they offer the simplest explanation for the known facts; whenever we discover the true explanation for biological phenomena it is almost always dynamic, complex, and sophisticated beyond our imagination. How can we keep ourselves aware of the gaps and anomalies in our knowledge? We must start by displaying to our students, perhaps in a single field, how flimsy is our understanding in the hope that they will retain a healthy scepticism when offered specious explanations. In the field of postgraduate training we must resist any change towards postponing examinations until the completion of training. Specialist diplomas in many other countries are awarded on completion of training. This appears to put a final seal on the candidate's knowledge. The British practice of taking postgraduate examinations during training tacitly acknowledges the area of learning beyond the scope of formal examinations. In the field of scientific communications we must control our innate desire for orderly and satisfying conclusions, since there is very little firm ground of knowledge. A single idea falsifying a previous hypothesis is much more valuable than a verbose report apparently confirming previous studies. For the same reason all results should be recorded by the author of a scientific report; some that

appear irrelevant to him may trigger ideas in others. Provided an author can validate his methods and measurements he should not be expected to justify results that run counter to established ideas. He has achieved his purpose by refuting current doctrine. The demolisher should not be asked to create another, equally insubstantial, hypothesis. Review articles and lectures have rightly gained in popularity in recent years. In them an expert sets up-to-date reports into the background knowledge. The reviewer is usually given a mandate to present an orderly, comprehensible statement with firm, clear-cut conclusions. It would be chastening if such experts from time to time highlighted the discrepancies, the anomalies, and the gaps in knowledge. Of what value is the display of ignorance to ourselves? In the field of clinical medicine and surgery every practitioner is a potential researcher. All of us have opportunities to recognize unique phenomena or develop original ideas. It is sometimes the chance observation of a phenomenon that cannot be explained, but which seems to have been reliably detected, that may trigger off a discovery. If we concentrate only on what we know, or think we know, we shall not recognize the illuminating discoveries that present themselves to us. It is often said that a fresh recruit to a scientific discipline is most likely to produce new ideas. This may well be because he is not inhibited by the weight of literature. Trite explanations dull the perception and also undermine the confidence of observers that they could detect a phenomenon overlooked by the cognoscenti. If we all acknowledge our small understanding, then we are all capable of the mobility of thought that accepts fresh ideas-both our own and those of others. R M KIRK

Editorial: Medicine and the gaps in our knowledge.

Annals of Royal July College of the Surgeons 1975 The expansion of scientific enterprise has generated a vast accumulation of documented facts...
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