Know-what

The learning of information is the bread and butter of medical school; without it, you’ll have nothing substantial to contribute. This is reflected in the sheer volume of examinations which require us to display our cognitive prowess: given this particular context, respond with the relevant information. Which molecule is involved in this metabolic pathway? What is the diagnosis? What is the likely causative organism?

We need to know the answers to questions so that we can make informed decisions with patients. What is the correct dose to prescribe? What stage of chronic kidney disease is represented by these blood tests? What is the risk of haemorrhage on this anticoagulant? What is their Wells score? What are my options, doctor?

Good doctors are informed and informing. However, knowing-what is insufficient. If all we need is information recall, doctors are no more than Google searches with stethoscopes.

Know-how

Learning productivity is the knife and fork of medical school; without it, you won’t make the cut. Medical schools need to produce us, and fast. This is reflected in the time pressure which looms over us in medical school: get it done. Given this particular problem, respond by sorting it out. Take a history and perform an examination. Insert an intravenous cannula using aseptic technique. Use your non-free free time effectively. And whatever you do, be finished within 14 minutes.

We need to be efficient so that we can deliver the care that patients need. We need to get things over (e.g. ward rounds). We need to get things under (e.g. bed pans). We need to get things out (e.g. appendices). We need to get things in (e.g. catheters, index fingers).

Good doctors are produced and productive. However, knowing-how is insufficient. If all we need is to be productive, doctors are no more than Toyota engines with stethoscopes.

Know-who

Learning communication is the Burgundy aperitif of medical school; it’s not to everyone’s taste but it’s the ‘done thing’. This is reflected in the ‘microskills’ in which we are trained along our undergraduate journey, enabling us to navigate our way through a consultation from open questions to closed, facilitated by gestures, sounds, summarising and signposts all the way home.

We need to be good at relating so that we can treat patients as persons. As doctors, we need to read people, not just blood results. We need to see patients as subjects,not just objects. We need to acknowledge their experience, expectations, desires, beliefs, culture and community, and those of our own too.

Good doctors are related and relating. However, knowing-who is insufficient. If all we need is relationality, doctors are no more than grandmothers with stethoscopes.

Know-why

Learning ethics is the after-dinner mint of medical school; it’s tacked on the end and not measured in the bill. This is reflected in its absence from the mainstay of the medical curriculum. Ethics sessions tend to be reduced to know-what (state the principles), know-how (exhibit professional behaviour), or know-who (communicate nicely).

Good doctors work ‘for the benefit of the sick’, as the Hippocratic Oath says (U.S. National Library of Medicine, 2012). Even if gifted with impeccable know-what, know-how and know-who, we might be no more than civil servants with stethoscopes, with ‘GMC’ and ‘NHS’ embroidered on our lanyard.

Good doctors do not merely provide answers for questions, nor actions for issues, nor interactions with personalities, but help for someone in a ‘predicament’ (Notre Dame Center for Ethics and Culture, 2014). To do good for patients, we need to know what is good for them. For this reason, ethics has been termed ‘the heart of healthcare’ (Seedhouse, 1998). It is the fundamental ‘why’ of medicine, reflected in our principles, actions and character. ‘The culmination in a right and good healing action is what constitutes medicine qua medicine’ (Pellegrino et al., 1981, p.211).

Good doctors know-what, know-how, know-who and know-why.

Dr Luke Martin

29/06/2018

REFERENCES

Notre Dame Center for Ethics and Culture, 2014. Medicine as moral enterprise [online]. Accessed 29/06/2018 at: https://www.youtube.com/watch?v=h6Em4VFE-7I

Pellegrino, E.D., Thomasma, D.C., 1981. A philosophical basis of medical practice. Oxford: OUP

Seedhouse, D., 1998. Ethics: the heart of healthcare (2nd ed.) Chichester: John Wiley & Sons

U.S. National Library of Medicine, 2012. Greek medicine [online]. Accessed 29/06/2018 at: https://www.nlm.nih.gov/hmd/greek/greek_oath.html