Embracing Ignorance
The Uncommon Pathway to Problem Solving
When I picture ignorance, I think of comedy. I think of Homer Simpson. I think of babies in high chairs slopping their food all over their faces. No one cares. They’re ignorant, and no one gives a crap. What I don’t think of when I think of ignorance are experts and problem solvers. It turns out that might be an ignorant point of view.
Ignorance is not just a blank space on a person’s mental map. It has contours and coherence, and for all I know, rules of operation as well. So as a corollary to [the advice of] writing about what we know, maybe we should add getting familiar with our ignorance, and the possibilities therein for writing a good story.
Those were the words of author Thomas Pynchon, in his introduction to a collection of novellas, Slow Learner. On the surface, ignorance is defined as the act of unknowing, of being unaware, of exisisting in a chronic state of unlearnedness. This may at first seem to be opposed to a state of expertise and advanced problem-solving, and perhaps it is—if we consider ignorance a static state of being. But, as Pynchon suggests, ignorance itself may be something to explore, to celebrate perhaps.
The late Dr. Lewis Thomas, once described as the poet-philosopher of medicine, but perhaps best known for his sometimes whimsical essays bringing the wonders of science to the masses, certainly celebrated ignorance when he coined the quote,
The greatest of all the accomplishments of 20th century science has been the discovery of human ignorance.
Even Bill James, of “Moneyball” fame, once gave a lecture entitled “Battling Expertise with the Power of Ignorance.”
There might be something to this.
As a physical therapist, I’m familiar with back pain. So, let’s use back pain as an example for how avoiding ignorance, how forgetting to acknowledge that sometimes just we don’t know something, can lead us astray.
Back pain has been described as a 20th century medical disaster. If we think the 21st century would have brought some improvement in that state, we can rest assured it has not. Research points consistently to increasing costs, increasing divergence from practice guidelines, and worsening outcomes for patients with back pain.
Back pain treatment costs our health system almost as much as care for all cancers combined.
Yes, you read that correctly. The most recent comparative estimates put back pain at just below $90 billion and costs for all cancer care just above $90 billion. What in the world can make something with a positive prognosis cost as much as a devastating collection of diseases, often resulting in expensive end of life care?
I suggest that ignorance plays a role here, but not in the way you might first assume. The unintentional denial of ignorance by the medical community has directly contributed to the disaster that is back pain. Multiple care pathways, unnecessary tests, and cost over-runs can all trace their roots to the simple fact that we don’t know what causes back pain, but we pretend we do.
To understand this, we need to first delve into that question ourselves:
What causes back pain?
For a very, very small subset of patients, there is an answer for this, but for the vast majority of patients with back pain, we don’t actually know what causes it. Anywhere from 85-90% of back pain ends up with the label “nonspecific” back pain. “Nonspecific” is a fancy way for health professionals to say, “we don’t know.” You may have also heard of the term “idiopathic,” which means similarly, “arising from an unknown cause.” In the case of back pain, the clear majority of cases fall into this vague landscape of nonspecific in nature.
The fact that we don’t know what causes 85% of back pain cases almost seems inconceivable given technological advances in medicine.
However, it seems the human body is the limiting factor in this instance. Scientists have proposed likely culprits for back pain, including everything from muscles and ligaments, to spinal discs and facet joints, to Vitamin D deficiency! However, the manner in which our nervous system is wired prevents patients with back pain from being able to detect which tissues are the culprit.
Described briefly, sensory input from multiple tissues in the back travels along the same nerve, an act of physiological efficiency called convergence. We also lack the same sensory discrimination and body part awareness in our backs that we have in more task-critical body parts like our hands. This results in information from several segments traveling along the same neural pathway without the ability to tell where it’s coming from.
The end result? Clinical special tests for back pain are poorly reliable and produce questionably valid results. This is not because we can’t figure out better tests, but because our bodies can’t actually tell us what exactly is wrong. Likewise, technological diagnostics, like MRI studies, are also of surprisingly limited value in detecting back pain with research consistently demonstrating poor correlation between diagnostic imaging findings and back pain.
And, here is the dilemma: Medical professionals, instead of acknowledging that they can’t figure out exact origins of back pain have created a multitude of systems, tests, poor correlations, and ultimately an entire culture of mismanagement for this disorder.
If you arrive at your health provider with back pain, you are likely to hear stories of a faulty disc, a blown-out jelly donut. You may hear that you have spinal instability, a disorder Jerome Groopman handled excellently in his treatise, “A Knife in the Back,” in 2002. This instability diagnosis, albeit faulty and without substantiative evidence supporting it, has led to the medical disaster that is spinal fusion surgery. If you have back pain, you almost certainly will get an MRI to “see what’s going on” in your back, under some false guise that it can actually do that.
This all would have been a lot more simple if we could have just admitted we didn’t know and embraced that ignorance.
To acknowledge the ignorance of a cause of low back pain is to also commit to a learning process. Ceasing to pry for a specific cause leads one down a different path. On this path we can put aside poor tests and inefficient management strategies. On this new path we can open ourselves up to innovation and develop new methods to treat back pain.
One strategy scientists and clinicians are using to investigate and treat low back pain is called classification-based treatment. In this model, several factors are identified through complex statistical analysis and come together to predict response to treatment. In the classification model, patients can be put into groups likely to respond to a specific treatment. One of the keys of this model is that patients don’t need to be given a binding label for the specific cause of their symptoms. The use of classification models has resulted in superior results compared to traditional patho-anatomical models that strive for a specific cause. It’s a system born from ignorance, designed to cope with an existing ignorance, and it’s a system that works.
A group of educators in medicine have taken the acknowledgement of ignorance a step further and created a Curriculum on Medical Ignorance based at the University of Arizona. Their scientific yet light-hearted approach to ignorance has begun to differentiate types of ignorance important in problem solving. Inspired by the aforementioned Lewis Thomas, Marlys Witte, MD, the founder of the institute, has identified the critical role of ignorance in problem solving. Known Unknowns, Unknown Unknowns, Errors, and Taboos are all aspects of ignorance that her students explore. Says Witte on her website, “Questioning is the basic process of science.”
Witte and others who explore and and embrace ignorance view it as a critical aspect of continued learning. Instead of reaching a certain level of knowledge and pulling back from the tables satiated, life long learners have the confidence to be present and aware of what they don’t know. Only then can the questions arise that will cause real change in what we do know.
Ignorance is not an end point. It’s not a static state. Ignorance isn’t permanent. Instead it’s the tool that enables one to learn. Ignorance is the spark that ignites scholarly inquiry.
Ignorance: the secret weapon of the expert.
