Examining "Unknown Knowns" in Medicine
We should know better. We are willfully blind.
A few weeks ago, I briefly examined a way of thinking that characterizes different types of knowledge as known knowns, known unknowns, and unknown unknowns. I think this is useful both as a knowledge classification system and a way to shoehorn Donald Rumsfeld into an article about medicine. Eagle-eyed readers and matrix enthusiasts, however, undoubtedly noted that I neglected to mention the obvious fourth category: unknown knowns.
Unknown knowns are ideas that we're aware of on some level but, for whatever reason, choose not to admit to ourselves. A more elegant moniker for this concept might be willful blindness. In the Rumsfeldian world, an example of willful blindness may have been the treatment of prisoners at Abu Ghraib.
In surgery, a common example is continuing to perform a procedure even in the face of evidence that it's either outdated or of little benefit: orthopedists performing arthroscopies on arthritic patients when washing the joint out would be just as effective, or the stubborn persistence of gastric banding in spite of mounting data in support of sleeves or bypasses. We know what the right answer is, but for some reason, we do something else. We should know better. We are willfully blind.
The impetus for willful blindness probably comes from a number of sources, but unfortunately the motive — subconsciously or otherwise — is frequently financial. Margaret Heffernan explored this idea in her aptly-titled book from a few years ago called “Willful Blindness: Why We Ignore the Obvious at Our Peril.”
In one section, Heffernan looks at the propensity of some surgeons to perform expensive operations that aren't strictly necessary, presumably for monetary gain, and concludes that the offenders are making the same cognitive errors as the people ultimately responsible for the subprime mortgage crisis or the Deepwater Horizon oil spill.
Pursuit of financial incentives, she argues, keeps us from thinking clearly, and simultaneously chills our willingness to criticize ourselves or our colleagues. A quote in her book from an orthopedic surgeon was especially telling: “The minute you see dollar signs in your patient's eyes, it changes how you think.” And not for the better.
I wonder whether this sort of economically-motivated willful blindness is rooted more deeply in the psyche of the American doctor than anecdotes about a few rogue orthopedists might imply. Our history certainly suggests as much: the American Medical Association (AMA) has, since at least the 1920s, again and again joined with insurance companies (or whatever partner of convenience happened to be available) to make universal healthcare — allowing all Americans access to the services that we provide — politically impossible.
The reasoning has typically been a desire to avoid “socialized” medicine (still a potent pejorative nearly 30 years after the fall of the Berlin Wall), a defense that remains as politically effective as it is logically suspect. Why would an association of physicians not want more people to have access to healthcare?
Occam's scalpel leads us to an easy answer. The AMA's raison d'être is to protect the interests of doctors, and so-called socialized-medicine would almost by necessity require us, as a group, to accept a pay cut.
Don't get me wrong — getting paid well isn't inappropriate, and the AMA is just doing its job. But there's real dissonance in the expectation that on one hand our professional association should protect our financial interests (even at the cost of denying healthcare to millions of people), but on the other hand that we should ignore opportunities to make a little extra scratch by diligently avoiding unnecessary interventions.
There's a fundamental inconsistency here, and one that I suspect many physicians long ago identified, but, for whatever reason, have chosen to ignore. We should know better. We are willfully blind.