?Don't think zebras?: Uncertainty, interpretation, and the place of paradox in clinical education

Abstract

Working retrospectively in an uncertain field of knowledge, physicians are engaged in an interpretive practice that is guided by counterweighted, competing, sometimes paradoxical maxims. "When you hear hoofbeats, don't think zebras," is the chief of these, the epitome of medicine's practical wisdom, its hermeneutic rule. The accumulated and contradictory wisdom distilled in clinical maxims arises necessarily from the case-based nature of medical practice and the narrative rationality that good practice requires. That these maxims all have their opposites enforces in students and physicians a practical skepticism that encourages them to question their expectations, interrupt patterns, and adjust to new developments as a case unfolds. Yet medicine resolutely ignores both the maxims and the tension between the practical reasoning they represent and the claim that medicine is a science. Indeed, resolute epistemological naivete is part of medicine's accommodation to uncertainty; counterweighted, competing, apparently paradoxical (but always situational) rules enable physicians simultaneously to express and to ignore the practical reason that characterizes their practice.

Aconselhamento em contracepção: grupo de capacitação de profissionais médicos do Programa de Saúde da Família

“…Among the innovative tendencies, Souza (1998) highlights the work of Hunter (1996), in the United States, with the introduction of literature into the medical course, emphasizing the need to develop the narrative competence of future physicians. Narrative competence means the ability to adopt different perspectives and to follow the chain of complex stories, often chaotic, that the patient offers.…”

Participatory learning: a Swedish perspective

“…8 Clinical decision making is not an entirely logical and deductive process; experience, context, and familiarity with the subject and/or the patient are other important components. 9 The framing of the decision in a well structured clinical trial differs a lot from the unstructured framing of the decisions in clinical practice. 10 Especially in primary care decisions can have complex medical and psychosocial dimensions.…”

Endorsement, Prior Action, and Language

“…Trusted advice is crucial because medicine lacks rules that can generally and unambiguously be applied to every case at hand [10], thus increasing physicians' belief in personal or trusted experiences above scientifically rigorous, impersonal dataespecially in instances of uncertainty. While the medical field has sought to embrace evidence-based medicine over anecdotal decision-making [15], the influence of anecdotal evidence, along with peer-to-peer discussions, still plays a major role in clinical decision making [6,8,10].…”