Mass extinction of life is imminent

When we chose the cover for this month's issue, the author advised care in selecting an image from the review of visual arts in hospital (JRSM 2010;103:490–9). Abstract art, he explained, makes patients feel uncomfortable, one of the messages of the paper. But the job of medical journals is to shake readers from their comfort zones. Clinical medicine is a place of uncertainty and clinicians are poorly trained at dealing with the limits of their knowledge. Confidence is king and ignorance an untouchable. While the culture of medical practice is being transformed by our information age – from paternalism to shared decision-making – it still takes extreme bravery for a clinician to admit ignorance in front of clinical colleagues or patients, not least because clinical colleagues and patients expect a knowledgeable answer. Yet medicine's bond with ignorance is ancient. The oracle of Delphi – and this issue of JRSM has a minor Delphic theme – proclaimed Socrates the wisest man of his age. Socrates argued that this was because he was prepared to accept the limits of his knowledge and unafraid of acknowledging his ignorance. Murray Enkin, an obstetrician from Canada, proposed seven stages of ignorance to summarize his clinical career ( Box 1). The seventh and highest stage of ignorance, he hypothesized, equated mostly closely with wisdom. Box 1 Seven stages of ignorance First stage: Innocence. You know you don't know, but you’re sure you can learn… Second stage: The facts. You know you still don't know, but facts are facts. Third stage: Naivete. You know what to do, but don't know how to do it. Fourth stage: Frustration. You know you don't know, but know that others know. Fifth stage: Expertise, the danger stage. You think that you know, and others think that you know. Sixth stage: Pyrrhic success. You know that you don't know, but others think that you know. Seventh stage: Ignorance. You know that you don't know, others know that you don't know, and it doesn't matter. From: Enkin M. The seven stages of ignorance. Birth 2008;35:169–70 The Socratic method is popular with medical teachers. Socratic dialogues often find their way into medical journals, as with this issue (JRSM 2010;103:484–9). But this appreciation of ignorance struggles to find its way to the frontlines of patient care. Clinical medicine remains a hard-nosed enterprise unable to eliminate the dynamics of power between doctor and patient. ‘Wise medical instructors do not fill students’ heads with facts,’ write our budding Platos, ‘but adopt a feigned position of ignorance from which to ask probing questions so they arrive eventually at insights that are the true prerequisite for gaining knowledge’. Unfortunately, those same students only realize many years later, possibly when they become medical instructors, that although knowledge is good, ignorance is not a professional sin. The JRSM's Socratic dialogue concludes with Athena, Goddess of Wisdom, advising that clinicians must hold their medical knowledge lightly and with humility, and constantly ask questions. She might also add that medicine must reconnect with the ethic of human kinship, by which the authors of an editorial on social governance argue that we should understand that as humans we share one humanity, live on one earth, and that our values, decisions, and choices affect others (JRSM 2010;103:475–7). Either that or we risk a sixth mass extinction, argues Dennis V Razis of the Delphi Society in Athens (JRSM 2010;103:473–4). More humility and greater human kinship might be important milestones on the path of reinventing the clinical professions, repairing the damaged relationship between doctors and managers – highlighted by your contributions to this issue (JRSM 2010;103:511–12) – and saving the planet from the catastrophe of the human species. As Razis puts it: ‘The risk of mass extinction of life is real and possibly imminent’. Where is Socrates when he is needed most?

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