The historical inertia of medical knowledge 🧵
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SARS-CoV-2 has introduced an unprecedented level of uncertainty into the medical field.
One of the central challenges in medicine is how doctors handle uncertainty.
Medicine, by its nature, is a discipline that strives to reduce uncertainty as much as possible.
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One of the central challenges in medicine is how doctors handle uncertainty.
Medicine, by its nature, is a discipline that strives to reduce uncertainty as much as possible.
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Doctors are trained to make decisions based on the best available evidence.
Their clinical judgment often relies on the assumption that most of the relevant knowledge is known or at least knowable.
This assumption has been deeply embedded in medical education.
The emphasis is placed on mastering a fixed body of knowledge.
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Their clinical judgment often relies on the assumption that most of the relevant knowledge is known or at least knowable.
This assumption has been deeply embedded in medical education.
The emphasis is placed on mastering a fixed body of knowledge.
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Doctors are trained to rely on certainty.
The pandemic presented an evolving scientific landscape that required flexibility and the ability to work with incomplete or provisional data.
What happens when uncertainty and ambiguity become permanent conditions of life?
They make traditional structures of authority, including medicine, less stable.
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The pandemic presented an evolving scientific landscape that required flexibility and the ability to work with incomplete or provisional data.
What happens when uncertainty and ambiguity become permanent conditions of life?
They make traditional structures of authority, including medicine, less stable.
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Medicine, historically built on solid foundations of knowledge, is now being forced to operate in a state of constant flux.
It is problematic for many practitioners.
Doctors should be able to balance the need for immediate action with the understanding that their knowledge may soon be rendered obsolete by scientific breakthroughs.
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It is problematic for many practitioners.
Doctors should be able to balance the need for immediate action with the understanding that their knowledge may soon be rendered obsolete by scientific breakthroughs.
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Humans have a limited capacity to process new information.
Particularly in situations where that information is complex and rapidly changing.
Doctors, who are already dealing with heavy workloads and the day-to-day demands of patient care, may find it impossible to keep pace with the flood of new research.
The reliance on established guidelines, protocols, and consensus opinions becomes a coping mechanism.
They manage information overload by deferring to institutional sources.
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Particularly in situations where that information is complex and rapidly changing.
Doctors, who are already dealing with heavy workloads and the day-to-day demands of patient care, may find it impossible to keep pace with the flood of new research.
The reliance on established guidelines, protocols, and consensus opinions becomes a coping mechanism.
They manage information overload by deferring to institutional sources.
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Medical knowledge and practice are inherently conservative.
Deeply embedded in tradition.
While science is always evolving, the medical profession tends to change its paradigms only gradually.
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Deeply embedded in tradition.
While science is always evolving, the medical profession tends to change its paradigms only gradually.
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This inertia isn’t just a matter of slow individual adaptation.
It reflects broader social, institutional, and cognitive processes.
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It reflects broader social, institutional, and cognitive processes.
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The goal of medical training is to equip practitioners with reliable, evidence-based knowledge.
And to instill a reliance on well-established protocols.
This serves an essential purpose.
Preventing harm.
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And to instill a reliance on well-established protocols.
This serves an essential purpose.
Preventing harm.
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In the face of a novel, rapidly evolving threat like SARS-CoV-2, the conservative nature of the system becomes a barrier to adaptation.
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Remember how the germ theory of disease faced decades of resistance?
Similarly, the use of antiseptics, vaccines, and anesthesia met considerable opposition in their early stages.
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Similarly, the use of antiseptics, vaccines, and anesthesia met considerable opposition in their early stages.
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Such resistance is partly driven by the fact that medicine is a profession built on a long-standing trust in the stability of scientific knowledge.
New ideas challenge the safety and predictability that doctors have learned to value in order to protect their patients.
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New ideas challenge the safety and predictability that doctors have learned to value in order to protect their patients.
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In the context of SARS-CoV-2, many doctors were initially trained in a system that focused on other types of respiratory infections.
Such as influenza or tuberculosis.
The protocols for managing respiratory diseases have been relatively stable for decades.
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Such as influenza or tuberculosis.
The protocols for managing respiratory diseases have been relatively stable for decades.
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The rapid accumulation of new data about SARS-CoV-2 requires an intellectual shift that is not easy to make.
How do you reconcile decades of clinical knowledge and practice with the sudden demand to accept and integrate new information?
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How do you reconcile decades of clinical knowledge and practice with the sudden demand to accept and integrate new information?
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Institutions play a central role in maintaining the inertia of medical knowledge.
Hospitals, medical schools, and professional organizations are structured to ensure that doctors adhere to established standards of care.
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Hospitals, medical schools, and professional organizations are structured to ensure that doctors adhere to established standards of care.
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These standards are often based on clinical guidelines and protocols that take years to develop, review, and implement.
Once protocols are in place, they provide a sense of security.
And a shield against liability.
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Once protocols are in place, they provide a sense of security.
And a shield against liability.
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Doctors are incentivized to follow these guidelines because doing so protects them legally and professionally.
These same protocols, developed in periods of stability, become obstacles when the situation demands rapid change.
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These same protocols, developed in periods of stability, become obstacles when the situation demands rapid change.
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Yet the process of changing institutional protocols is slow and cumbersome.
It’s leaving many doctors reliant on outdated information.
How can institutions balance the need for reliable, stable guidelines with the necessity of rapid adaptation?
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It’s leaving many doctors reliant on outdated information.
How can institutions balance the need for reliable, stable guidelines with the necessity of rapid adaptation?
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Doctors working within large institutions are isolated from cutting-edge research.
While academic physicians closely tied to research centers might be quick to adopt new findings, many doctors in community hospitals or private practice rely on more traditional channels for their updates.
These channels (medical journals, conferences, and professional associations) are slow-moving by design.
They’re slow because they aim to filter and validate new information before it is widely disseminated.
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While academic physicians closely tied to research centers might be quick to adopt new findings, many doctors in community hospitals or private practice rely on more traditional channels for their updates.
These channels (medical journals, conferences, and professional associations) are slow-moving by design.
They’re slow because they aim to filter and validate new information before it is widely disseminated.
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Much of what doctors learn during their training becomes deeply ingrained in their practice.
Unlearning or updating this knowledge can be difficult.
It’s cognitive anchoring.
Initial knowledge or first impressions continue to influence decision-making long after new information has become available.
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Unlearning or updating this knowledge can be difficult.
It’s cognitive anchoring.
Initial knowledge or first impressions continue to influence decision-making long after new information has become available.
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In the case of SARS-CoV-2, many doctors’ initial understanding of the virus was formed during the early months of the pandemic.
When little was known, and comparisons to influenza were common.
As new information emerged (airborne transmission, the role of asymptomatic carriers, the immune system’s response) these early ideas continued to shape the thinking of many practitioners.
Even as new research emerged, many doctors found it difficult to adjust their practices.
Because they were anchored to their initial perceptions.
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When little was known, and comparisons to influenza were common.
As new information emerged (airborne transmission, the role of asymptomatic carriers, the immune system’s response) these early ideas continued to shape the thinking of many practitioners.
Even as new research emerged, many doctors found it difficult to adjust their practices.
Because they were anchored to their initial perceptions.
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This raises a profound question about the nature of medical education.
How can the system ensure that doctors remain flexible, adaptable, and open to updating their knowledge in the face of rapidly evolving science?
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How can the system ensure that doctors remain flexible, adaptable, and open to updating their knowledge in the face of rapidly evolving science?
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Another factor contributing to the inertia of medical knowledge is the strong socialization that occurs within the medical profession.
Doctors are socialized into a particular worldview.
One that emphasizes authority, expertise, and responsibility.
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Doctors are socialized into a particular worldview.
One that emphasizes authority, expertise, and responsibility.
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This professional identity is reinforced through the hierarchical structures of hospitals and medical organizations.
Senior doctors, who have been practicing for decades, often serve as role models for younger doctors.
The professional norms that these senior doctors impart to their juniors are based on decades-old knowledge that may not account for the unique challenges of novel pathogens.
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Senior doctors, who have been practicing for decades, often serve as role models for younger doctors.
The professional norms that these senior doctors impart to their juniors are based on decades-old knowledge that may not account for the unique challenges of novel pathogens.
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A doctor’s legitimacy is often tied to their adherence to established norms and practices.
Deviating from these norms by following new, rapidly changing guidelines can be seen as risky.
And potentially illegitimate.
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Deviating from these norms by following new, rapidly changing guidelines can be seen as risky.
And potentially illegitimate.
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