Sunday, December 30, 2012

Just Because

     In adherence with the anesthesia board re-certification process and maintenance of my medical license, I've been taking an online, self-study continuing medical education (CME) exam. In all honesty, I've been avoiding it for the last six months. Since the 30 hours of credit expire on December 31, 2012, and I've already paid $300 for the exam, I figured I may as well suck it up and get 'er done over the holidays. The questions range from absurdly easy ones like this (the answer is "Duh!"):


  Which of the following is most likely to occur in rhabdomyolysis?
  1. Hyperkalemia
  2. Metabolic alkalosis
  3. Hypercalcemia
  4. Hypophosphatemia

to redonkulously obscure ones like this (eliciting a head-scratching, hair-twisting "Huh?!"):

   In which of the following situations would a paired t-test be the MOST appropriate statistical test?
  1. Determining the neurologic outcome (graded as "intact," "neurologic compromise," or "dead") in patients with subarachnoid hemorrhage due to intracranial aneurysm
  2. The presence of headache following donation of autologous blood in 50 subjects, each of whom donates 2 units of blood--once with a fluid bolus and once without
  3. Heart rate change from baseline measured in the same individual given neostigmine with glycopyrrolate
  4. Blood pressure changes with propofol versus thiopental for induction of anesthesia in 1000 patients
    To obtain CME credit, I had to answer all 100 questions correctly. As much as I'd like to say I got them all right on my first attempt, I had to go back and reset the responses on more than just a few, after taking time to read through the scholarly discussion provided with each question. The discussions are actually pretty awesome. For me, doing lots of practice tests is the smartest way to study for a written exam. It's no secret that exams don't exclusively test knowledge: they measure how well you take a test. By studying a multitude of questions and answers, you gain an understanding of how they're structured, and even if you don't know the answer off the top of your head, you can usually eliminate at least two choices based on wording alone. "Always, " "only," and "never" are pretty reliable red flags. When you've got it narrowed down to two choices, but you're still unsure, an educated guess will typically produce the correct response. Wrong answers are usually A) the result of not reading the question or answers thoroughly OR reading too much into them, B) a knowledge deficit, C) failure to apply existing knowledge logically, or D) ignoring gut feelings and changing your original answer. Never change an answer unless you're absolutely sure you got it wrong! If you happen to guess wrong, the discussions provide a brief review of the basic science or clinical pathways involved, walking you through a dissection of each scenario so you can determine for yourself why there is only one BEST response. Before I'm even halfway through a discussion, it's already evident why the correct answer is cut and dried. 
    After finally getting through the exam, I re-read the questions, and the answers seemed so simple and straightforward.  None of the material was new to me: I've seen it all before. In fact, I knew it all like the back of my hand when I took my initial written and oral boards in 2006, so it's more like assimilated information that's on hiatus...gone, but not forgotten, absorbed and committed to what I consider an even loftier level of knowledge: intuition. Much of my decision-making in anesthesia practice has its basis in what feels right, which is also how I live my life. I've never been one of those who can recite studies or regurgitate factoids when I'm being pimped onstage, which is probably why I despise the Socratic method of teaching. Real life patients and scenarios aren't textbook. Rarely (if ever) cut and dried, an evolving situation is nuanced, complex, and dynamic in nature, and it won't stand still while you're busy crunching data. Relying solely on logic and reason is myopic at best, eliminating the very real possibility that sometimes, shit just happens. That's when you just have to trust your gut and act accordingly.
     What is it that we think we know and how do we know we know it? Where exactly do we get all of our facts? Aren't there things we know just because--instinctual, intuitive knowledge that defies explanation or justification? Is something spontaneous and fundamental lost in translation when we know that we know, when we start thinking about thinking? In continuity with the universe, we beat our own hearts and breathe our own breaths. We don't have to think about these processes, we just automatically do them: they are central to our existence. It's only when we start thinking about these things that we feel anxious. Self-awareness leaves us wondering if there's something we've missed, ignoring the obvious because we're driven to complicate what's basic and simple, effectively permitting minutiae to supersede experience itself. Does how and why we breathe really matter as long as we're spontaneously breathing? Can all questions be answered at a molecular level, and do our answers always warrant a defense? Although the mechanics and physiology of automaticity have been fully elucidated, they still fail to explain the basic question: what is it that makes our hearts beat in the first place? Why isn't "because we're alive" enough of an answer? It's when "just because" becomes unacceptable that we separate ourselves from nature, and become dispassionate observers, victimized by existence, instead of engaged participants who are too busy enjoying now to worry about what's going to happen next. Here's the thing. I am my body and my body is me. I'm marvelously self-contained, a symptom of nature, a unique expression of the cosmos. I am my existence, not a victim of it. I am just because.

15 comments:

  1. Kris, it's hard for people raised on Western rationalism and science to accept that the things of this world cannot be understood or explained. They are simply what they are and how they happen to be. It is possible to explain how things work, but not why they work that way. The search for the why of things is the ultimate wild goose chase.

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    1. I agree. There's an arrogance in A to Z logic that's difficult to circumvent, especially in my field. Funny thing is, the answers seem to change all the time. The more we know, the more we find out how little we know, and that's very threatening to someone who wants definitive answers.

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  2. Congratulations on passing your exams Helena. I knew this would have been a done deal. The example questions you gave looked as if it was written in french to me, I couldn't even pronounce some of the words, let alone answer the question. That's why your a doctor and I'm not, hahahaha.

    Spot on about exams. One of my faults was always not thoroughly reading the question properly as I presumed I knew the answer only to find out that they had twisted one of the words, which changed the whole answer. Oh, and my other fault was first answering on a gut feeling, only to change my mind and then get it wrong.

    The human body is a fascinating thing, and I'll never knock education as there is so much we can learn about it. But when complex, complicated things happen, you have to think on your feet, use your common sense, dig deep, act quickly and do what you can to save that life so to speak. You can't refer to the text book, or do a quick internet search etc etc.. You are truly cut out for such a job Helena.

    Anyway, it's that big day and we soon approach the coming year. I hope you and your family all have a very Happy and wonderful New Year. Continue to provide us all with such great posts. :)

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    1. Thank goodness I only have to get recertified every ten years! Test-taking is part application of knowledge, part navigating through verbage, and part luck. One of the reasons I enjoy my work is because it combines the best of both worlds--factual knowledge and intuition--the art and science of medicine. Happy New Year to you, RPD...can you believe it's 2013?!

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  3. I love questions like these, and how quickly they rip holes in our comfort zone. The reality is that our so-called 'certainties' are all based on assumptions. Even a hard-core rationalist has to make the assumption that rationalism is an appropriate way to think about existence. I prefer to drink wine at moments like these.

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    1. I completely agree, Robert. I can't remember his name, but one of the researchers instrumental in unlocking the mysteries of the human genome is a devout Christian. Obviously, he's found a way to reconcile rationalism with his religious beliefs. I love Einstein's encapsulation of this quandary: "The scientist's religious feeling takes the form of a rapturous amazement at the harmony of natural law, which reveals an intelligence of such superiority that, in comparison with it, all the systematic thinking of human beings is an utterly insignificant reflection. This feeling is the guiding principle of his life and work."

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  4. Hyperkalemia what? You are WAY to smart for me. Congratulations on getting that exam over and done. You're right. It's strange what we know and how we know it, how some things are ever-present in our minds and others lurk in the dark recesses, prepared to come out when needed. Like you, I think that's pretty cool.

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    1. Ding, ding, ding! You guessed the right answer, Janene! Hyperkalemia means elevated potassium. And, there's a German word for tacit apprehension, knowledge that's ever-present and lurking in the dark recesses: Hintergedanke.

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  5. Helena,

    I always love your deep explorations of what we take as common place. You pose a difficult and insightful problem of knowledge and epistemology, and I assume that you are talking about different gradations of knowledge. You are astute enough to realize that you your advanced knowledge of anesthesiology places you and I in different spheres of intuition, mine in anesth. being nil.

    But, I think that the point you are making is based on a broader principle, right? That in life we tend to always emphasize knowledge over intuition. And, in fact there can come a point in ones level of expertise when knowledge might hinder intuition and practice. When I see a physician, I guess that I look for both, but solid, confident intuition persuades me more than a physician who spouts off all his textbook learning.

    Having said that, isn't it true that some people's intuition is sharper, more accurate that others, and if that is the case, how do you handle such problems? I had a doctor once with admit intuitions that I had appendicitis. I was in a third world country, with my American doctor. The doctor from the Dominican Republic contended that I was very ill but my white blood cell count was too low for appendicitis. My American doctor demanded that he remove my appendix immediately, and thankfully the Dominican doctor refused. I was just very sick and still have my appendix.

    I share this because some people can let intuition, prejudice, and premature conclusions obstruct good old book learning. On the other hand, maybe the Dominican doctor was relying on instinct as well.

    Anyway, you've got me thinking through this and I am persuaded by your comments. There definitely is a place for intuition, though the exact place is difficult for me to pinpoint.

    Thanks for such an engaging post,

    Darin

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    1. Interesting about the Dominican doctor. He probably doesn't practice medicine as defensively as the American doctor does. Personally, I've seen one too many cases where appendicitis was diagnosed based more on symptoms (soft) than signs (more evidential), only to find that it wasn't appendicitis or anything needing surgical management at all. There's a fine line between hair-trigger reactions and intuition, I think.

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  6. Great post!

    I have nothing to add except that I have learned there are 2 types of questions in life, those with an answer to help you succeed and those with answers to show you how you have failed.

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    1. I need to groove on that for awhile...have never thought of questions in this way :-D

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  7. Excellent post, very well said.

    We do not have the answer to where life comes from, and can only simulate such a thing, not actually do it. We do not have all the answers and possibly never will. Anyone that claims to know everything can not be believed. We can only assume and speculate, but we are much better off not wasting our time thinking about it.

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    1. I completely agree, PBS. Life itself is a mystery, and maybe the best solution is to just enjoy it for what it is.

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  8. Yes, there are things we know "just because." I think some of it is knowledge we retained and know is correct but cannot explain how we know it. That happens to me all the time. I know stuff "just because." I agree that too much thinking about the thinking, too much navel-gazing about the process, can often cause undue anxiety. We don’t have to think about breathing, we just do it. I love your line, "I am existence, not a victim of it. I am just because." Excellent, Kris, and I raise a glass of cheer to that! :)

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