Do Doctors Suffer from Prenosognosia?

I've been following Kent Bottles' fascination with the state of our knowledge about our knowledge for a while here and here, with particular interest paid to Donald Rumsfeld's famous phrase.

I've decided we need another term.

What do you call it when you can not recall the state of your previous ignorance?

If this sounds trivial, consider this: upwards of half of patients don't know what their physicians are talking about. In a word, it means doctors are not always the best teachers. Why is this?

Doctors master several necessities of effective teaching; knowledge, passion for the subject, and clarity of both staging and content delivery. However, there is one essential element that physicians understandably may not excel at- being able to step into the learner's shoes and explain the world in terms that they are familiar with.

For example, doctors' explanations often hinge on a grasp of anatomy far in excess of their patients' familiarity. A description of why back pain is muscular and not neurological may include several anatomical references that quickly overwhelm the patient's ability to keep up.

The real trouble is that doctors often don't know how much the patient does not know about anatomy, a kind of unknown unknown.

Interestingly, all doctors used to know how much patients don't know about anatomy, because all doctors were at this state of ignorance before their training. So it's not a simple unknown unknown, but rather a forgetting.

If doctors could better recall what it was like for them prior to their own education and training, then they might be better teachers, and patients might come away better aware of their conditions and more likely to adhere to their recommendations.

If we had a term for this, then perhaps we could more easily point it out and better train doctors to teach their patients. I propose the following term:

Prenosognosia

PRONOUNCIATION: pre-no-sog-NOH-zee-uh

MEANING: noun Unawareness of one's previous state of not knowing.

USAGE: "I don't understand my doctor, maybe she has prenosognosia- she talks to me like I've spent four years in medical school."

Shifting Power Dynamics

Tomi Ahonen's said "In the connected age, sharing information is power." He compares information sharing to the previous power move of information retaining, divvying out at the right time and place. 

Doctors are powerful people, and their source has so far been the later- information withholding. Patients must come to them, at their schedule and on their timetable. This is not to say they're power mongers; most physicians would prefer to be all things for their patients if there were enough hours in the day, and oftentimes work all of them. 

Much of medicine, and all of medical education is predicated on this withholding/dispensing model. Yet, as we edge deeper into Ahonen's connected age, patients will come to expect their health information to be shared, as easily accessible as their bank accounts and music purchases, always on and always updated to recent events and behavior, and they will expect (or demand) this before doctors are ready to provide it. 

Medical schools have a unique role. Unlike other developments in the profession, for example like the emergence of new diagnostics where students are playing catch-up to implementations already achieved in the field, these connected tools are foreign to the traditional structure of care delivery. Not only foreign, they're disruptive. Disruptions from information sharing tools like the Skin of Mine app (which I've written about here) will not be welcomed by clinicians who have structured their practice around dispensing information. This sets up a recipe for a very rough transition. Since medical schools are full of tech-savvy, idealistic students who are already structurally ensconced in an environment that combines learning, innovation, and the wisdom of senior faculty, this offers an ideal site to gracefully expose those established in the medical structure to these disruptive tools.

So, basically, medical schools can lead the way through these changes rather than play catch up. Someone has to pioneer these developments, it might as well be the digital natives who are already enrolled in safe medical testing ground.

The Age of Distribution: Social media in healthcare

Looking at these two asthma medications, it's not surprising that patients often confuse them. As Lawrence Martin, MD points out in 10 Common Misconceptions and Errors in Treating Asthma, when a patient becomes acutely short of breath, only the inhaler on the left will help, even though he or she will likely also own a maintenance inhaler like the one on the right.

This highlights a key distinction that's worth examining- the difference between knowledge acquisition and knowledge distribution in medicine.

Traditionally, great emphasis has been placed on the former. It's the stuff of eminent teachers and researchers, pathbreakers and groundbreakers. It's taught in hallowed halls and gathered by multimillion dollar machines.

Knowledge distribution, on the other hand, gets little fanfare. It has seen almost no growth since doctors stopped doing home visits. Patients come to a clinic, sit in a waiting room, and eventually get a few minutes to talk with their doctor to hear about the knowledge that's been gathered, and what to do about it.

This model works fine for some conditions, especially those with a quick, immediate fix. But for the majority of chronic, and costly, conditions, the information distribution element is crucial. Patients will live with these ailments daily, requiring significant understanding and by-in to their treatment. And while we often have great therapies, roughly half of all prescriptions go unfilled. This is one reason why a 15 minute office visit doesn't cut it.

All this is about to change.

We are entering a new era, where sophisticated communication tools are at our fingertips. With a smartphone and some clever apps, suddenly we aren't beholden to an office visit. Instead, doctors can get their message out to patients early and often. Those with asthma can be in continual contact with their physician, dialing in treatment to meet the evolving nature of this condition, rather than relying on a few visits yearly.

As chronic disease burdens mount, perhaps the focus will begin to shift away from knowledge acquisition and we will start to develop means of keeping more continual, low-level contact with these patients the gently nudge them towards optimized health. Perhaps medical school curricula will embrace social media and mobile apps, and a new wave of doctors will be able not only to acquire knowledge, but to also push it to where it counts.