LIMITS OF KNOWING
What is the internal experience of facing, or even simply recognizing, personal limitations in knowledge and knowing? How do societal expectations of physician wisdom, capability, reliability and liability contribute to this experience?
Uncertainty is everywhere in clinical practice (1). Most obviously, uncertainty may surround scientific facts and/or medical knowledge. A provider may a) not know certain information because that information is out of the scope of their daily practice; b) not routinely keep up with advances in specialty areas; c) have forgotten details due to rare utilization; or d) have never learned certain information because science has not yet progressed to offer such knowledge in the first place (2). Moreover, as physician-scientist Steven Wartman reminds us, collective “scientific and technologic progress will [only] continue to reduce the ability of physicians to solve patient problems singlehandedly,” increasing relative uncertainty and limitation at the individual doctor level (3).
But uncertainty in medical settings may also relate to what philosopher Gilbert Ryle deems “knowing how” (as opposed to “knowing that”—i.e., knowing facts or information) (4). “Knowing how” refers to knowledge obtained from first-person lived experience. It is unattainable by reading, listening or watching from “the outside.” A physician may, for example, find identification with a patient’s experience challenging due to the fundamental uniqueness of human bodies and ways they embody physical sensation (e.g., pain). Or a physician may lack exposure to diverse “ways of knowing,” such that certain approaches to knowledge and interpretation of experience (e.g., spiritual, cultural, intuitive) remain foreign and thus inaccessible in a given moment. Uncertainty around “knowing how” relates to what I call “hermeneutical insufficiency,” defined as an absence of the hermeneutical resources required to understand or empathize with non-universal lived experience (5). In many ways, hermeneutical insufficiency parallels the “fallibility” of all science; “no matter how sophisticated our measurements become,” a recent article in BMC Medical Ethics argues, “we remain limited in our ability to access the truth because of our fallibility as observers and…the intrinsic technical limitations of the instruments we use" (6). Critically, hermeneutical insufficiency is a precursor to hermeneutical injustice. Such injustice occurs when one’s experience is “obscured from collective understanding owing to a structural identity prejudice in…collective hermeneutical resource[s],” leading “even the most sympathetic social peers” to respond inadequately (5).
Acceptance of uncertainty, personal limitation and capacity for ignorance is thus required for patient-centered, bias-conscious care. Yet acknowledging uncertainty of any sort in medicine remains challenging for many reasons: years of training throughout which getting “the most right answers is rewarded;” fear of upsetting or disheartening patients or colleagues; losing hard-won trust; pressure on self by self (7-9).
A patient asks his physician why he has been experiencing severe headaches for several weeks. Standard workup (exam, labs, imaging) is unremarkable. The physician says to the patient: “we have performed many studies, and I’ve considered a range of clinical possibilities, but I still don’t have a diagnosis for you.”
A patient asks her physician why her cancer is not responding to the indicated therapy. The physician has to tell her: "I don't know.”
A patient's daughter asks if there is an element of "possession" (per religious/cultural beliefs) to her mother's condition. The physician says, “I am not sure how best to respond to that question.”
NEJM Knowledge+ Team. Exploring the ACGME Core Competencies. NEJM Knowledge+. June 2, 2016. https://knowledgeplus.nejm.org/blog/exploring-acgme-core-competencies/.
McGovern R, Harmon D. Patient response to physician expressions of uncertainty: a systematic review. Ir J Med Sci. 2017;186:1061–1065.
Wartman, SA. The Role of the physician in 21st Century Healthcare. Nota Bene: Ideas for Thought Leaders. Association of Academic Health Centers. 2017.
Epistemology. Stanford Encyclopedia of Philosophy. https://plato.stanford.edu/entries/epistemology/
Kidd IJ and Carel H. Epistemic Injustice and Illness. J Appl Philos. 2017;34(2):172-190.
Kelly MP, Health I, Howick J et al. The importance of values in evidence-based medicine. BMC Medical Ethics. 2015;16.
Beck J. When Doctors Should Say 'I Don't Know.’ The Atlantic. February 29, 2016.
Onyedika E. Why It’s OK for Doctors to Say ‘I Don’t Know.’ PhysicianSense. June 19, 2019.
Puhl K. Physicians don’t know everything, and that’s OK. KevinMD. February 27, 2018.