The Seven Stages of Ignorance

And one man in his time plays many parts,His acts being seven ages. William Shakespeare, As You Like It My eighty-four years, more than sixty of them immersed in maternity care, have allowed me to collect a lot of information, and perhaps a little bit of knowledge. They have also given me time to pick up a lot of ignorance. I have been given ample opportunity to share what I have learned with others; this has been enjoyable and easy. My accumulated ignorance is another matter. Sharing ignorance is much more difficult than sharing knowledge, but perhaps even more important. Modern technology is making it easy for us to acquire and share information—perhaps too easy. Today, with our emphasis on information-based maternity care, we have more information than we know what to do with. We don’t know what to believe, what to assimilate, what to ignore, how to interpret. The information keeps pouring in. Perhaps it’s not more information that we need, but more ignorance. This idea is neither original nor new. Will Rogers, who died in a plane crash in 1935, said “It ain’t so much the things I don’t know that get me into trouble, it’s the things I know that ain’t so.” Unlike many of his colleagues, one of my professors in medical school was honest enough to confess “Half the things I’m telling you are probably wrong. The trouble is I don’t know which half.” An old Italian proverb stated it succinctly: “Chi sa, non sa. Chi sa che non sa, sa.” (He who knows, does not know. He who knows he does not know, knows.) Ignorance does not come in neat transferable, transmissible packages. We have no good taxonomy of ignorance. It is at the same time both general, and personal. To quote Will Rogers again, “Everybody is ignorant, only on different subjects.” We learn (if we are lucky) from our mistakes, but we don’t have time to make them all by ourselves. Can we learn from the mistakes of others? I don’t know. My long and idiosyncratic personal path to ignorance may or may not be relevant to others; but it is at least possible that some of you who read this may find yourselves on trajectories similar to my own. You may encounter some of the tempting tangents that led me astray. Perhaps some of the misconceptions I have held, some of the mistakes I have made, may resonate, and possibly be useful. Perhaps it would be enough if you find them entertaining. I had the chutzpah to choose Shakespeare’s seven ages of man as the template to relate my personal path to ignorance. He told it, not as we like it, but as it is. At first the infant, mewling… Once upon a time (like so many of us) I was young and idealistic. I wanted to be a great scientist, discover a cure for cancer and all the other ills that bother mankind. What caused disease? How to treat it. I was in that wonderful, delicious, innocent, first stage of ignorance. I didn’t know anything, and I knew that I didn’t know anything, but I knew that I could and would learn everything in medical school. Yes. Then the whining schoolboy, with his satchel I went to medical school, and learned the facts. Lots of facts. I learned to believe in facts. The “facts,” of course, were what my teachers knew and taught. Someone put it neatly: “If you tell an engineering student to memorize the telephone book, he will ask you “why?” If you tell a medical student to memorize the telephone book, he will ask you “by when?” I tried to be a good medical student, I tried to learn all the facts, but there were just too many of them. I was only a student. Soon I would graduate and be a doctor—then I would know everything too. Then the lover, sighing like furnace… I graduated. I had my MD. They called me Doctor. But something was still wrong. Doctors know best—but I still didn’t. Oh well, I was just an intern, I was optimistic, I expected to learn from experience. I had facts, but no experience. When I got out into practice I would know, because practice makes perfect. Practice makes perfect. Practice …. If you say it often enough, long enough, you come to believe it. Then the soldier, full of strange oaths and bearded I went into practice, but it didn’t work out the way that I had hoped. I could never get the experience I needed, I could never get enough. I would learn about one disease, but the next illness was a different story. I would treat one patient, but the next patient had a different problem. To get the experience, to know what to do, I would have to become a specialist. I was “only a GP.” It’s an interesting phrase, “only a GP.” We didn’t have “family doctors” in those days, we had general practitioners, and they were always referred to by the derogatory term “only a GP.” Everyone said “A GP is a doctor who knows less and less about more and more, until he eventually knows nothing about everything.” We were less aware of the corollary: “A specialist is someone who knows more and more about less and less, until at last he knows everything about nothing.” I loved general practice, but I became a specialist. And then the justice, in fair round belly… Soon I was an obstetrician, a real specialist, a bona fide frog in a nice little pond. I cared for my patients, and they appreciated my care. I was doing right and doing well. It was very pleasant, very comfortable. Too comfortable. It was seductive. Without being consciously aware of it, I slipped into the most dangerous stage of ignorance, the “I’m OK, you’re OK” stage, the “what-is-is-best” stage. It lasted too long, but it couldn’t really last. Deep inside I knew that what-is is not really best. I tried, weakly, to challenge authority. I put bandaids on what seemed to me to be most wrong. My plodding and prodding had little if any impact. I was an outlier, an outsider. Then Luck stepped in and took over. Family-Centered Maternity Care, which had seemed so right and so unobtainable, suddenly became fashionable. My city got its own medical school, and introduced the concept of Evidence-Based-Medicine, which became the new buzz word. Opportunity knocked and I answered the door. I jumped on the bandwagon. The sixth age shifts… It came almost overnight, I became a professor, wrote books, got a reputation, received honors. I had spent my life challenging authority. Now I was the authority. It was heady fare. I loved it. I loathed it. Just as I had long ago thought that my teachers knew everything, I realized that now my students—and perhaps even some of the people who read the books I co-authored—thought that I had the answers. But I knew that I didn’t. I wondered how long it would be before others found out how much I did not know. Or maybe they already did, and I didn’t know that either. Last scene of all, which ends this strange eventful history… T.S.Eliot asked “Where is the wisdom we have lost in knowledge? Where is the knowledge that we have lost in information?” Somehow, it is very satisfying to have reached this ultimate stage of ignorance, this stage of ultimate ignorance, to realize that information mutates, and knowledge withers (or rotates). To know that always someone will “know,” just as you did, only better—or at least more so. Perhaps the seventh stage of ignorance is wisdom. Perhaps. I don’t know.

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