In Praise of Ignorance (Seriously!), Epistemology (Sort of …), and the Circle of Least Confusion
2013; Elsevier BV; Volume: 120; Issue: 5 Linguagem: Inglês
10.1016/j.ophtha.2013.03.004
ISSN1549-4713
Autores Tópico(s)Ethics in medical practice
Resumo“Facts are stubborn things, whatever may be our wishes, our inclinations, or the dictates of our passion,” so said John Adams in his successful defense of British soldiers charged with murder in the Boston Massacre. At face value, his declaration emphasizes the difficulty (or the futility) of arguing against rock-solid evidence. But Adams' assertion may have relevance on another level for us today as investigators, reviewers, editors, and consumers of scientific information. I'll explain, but first please allow me to relate how this essay started as a recollection of Ophthalmology's history and digressed into a celebration of ignorance. It is traditional for a new editor, early in his or her tenure, to proffer a state of the journal perspective, detailing for the readership the origins of the periodical, its current health, and the editor's predictions for a glorious future. With hopes that you will not flip the page just yet, I shall be mercifully brief. Your journal dates to 1897 and its story is succinctly recalled in the excellent monograph Pioneering Specialists. A History of the American Academy of Ophthalmology and Otolaryngology, by Sharon A. Bryan (available at http://www.aao.org/about/history/).1Bryan S.A. Pioneering Specialists A History of the American Academy of Ophthalmology and Otolaryngology.in: American Academy of Ophthalmology, 1980: 16-22Google Scholar Early issues, as with many journals, were compilations of meeting papers and miscellaneous ephemera, distributed annually to the organization's fellows and members. The Transactions title first appeared in 1903 and was retired in 1978 as ophthalmology and otolaryngology continued their respective maturations as distinct specialties.2Truhlsen S.M. Revision of transactions.Ophthalmology. 1978; 35: 9Abstract Full Text PDF Scopus (1) Google Scholar, 3Truhlsen S.M. Whatever happened to the EENT specialists?.Surv Ophthalmol. 2013; 58: 92-94Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The new offspring, Ophthalmology, broadened its scope to include papers beyond those that had been presented at the Academy's annual meeting, setting the course for the journal as we know it today. More about the past, perhaps, in a future editorial. Ophthalmology's vital signs are robust. The journal receives far more meritorious submissions than its page allotment can accommodate, its impact factor is strong for a specialty periodical, its distribution is global and published manuscripts are increasingly international, its finances are solid, and AAO fellows and members routinely rate their subscription as one of the top benefits of membership. Thanks to the strong leadership of my predecessors; outstanding contributions by reviewers, editorial boards, and journal staff; and steadfast support from the Academy, the prognosis for Ophthalmology is favorable. More about the future, for sure, in an ensuing editorial. For the future is where things get interesting. In a thoughtful perspective in the year-long series of articles commemorating the bicentennial of the New England Journal of Medicine, Podolsky et al4Podolsky S.H. Greene J.A. Jones D.S. The evolving roles of the medical journal.N Engl J Med. 2012; 366: 1457-1461Crossref PubMed Scopus (22) Google Scholar reviewed the role of medical journals and concluded that their future “remains undetermined.” The authors opined, however, that readers' preferences will be critical: “which subscriptions they keep, which free content they browse—[these choices] will shape the decisions of journal editors, sponsors, and advertisers.” True, no doubt: journals cannot survive without a sustainable business model. But few would want to see any scientific publication fettering its tactical and operational plans to the most profitable revenue stream, especially if doing so compromises the journal's primary mission. For Ophthalmology, that aim is service, as affirmed in our statement of purpose on the journal's masthead: “Ophthalmology, the journal of the American Academy of Ophthalmology, serves society by publishing clinical and basic science research and other relevant manuscripts that relate to the sense of sight. Excellence is pursued through unbiased peer-review, the advancement of innovation and discovery, and the promotion of lifelong learning.” I briefly touched on the journal's aspirations for service in my inaugural editorial5Bartley G.B. Of metaphors, mission, mentors, and 50 000 thank yous.Ophthalmology. 2013; 120: 1-2Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and wish to elaborate a bit more here. The first sentence is straightforward. Ophthalmology will continue to feature clinical papers, as most of our readers are practicing ophthalmologists, but will consider, with alacrity, notable basic science investigations that have clinical importance or that carry the promise of future applicability. The inclusion of “other relevant manuscripts that relate to the sense of sight” is meant to comprise communiqués about health care policy, medical history, or even essays that describe the joys and challenges of being an ophthalmologist. The editorial board hopes that every issue will contain something enjoyable, as well as much that is educational, for every reader. The second sentence of the journal's declaration of purpose is more operational. Every thoughtful person knows that excellence rarely occurs spontaneously, but instead must be actively pursued. The first step in this direction is a commitment to authors and readers that our peer-review process will be as objective and unbiased as possible. The editor-in-chief, for instance, is prohibited from having any financial or consulting relationships with industry. (Of course, such solitude is relatively easy for an oculoplastic surgeon, perhaps second only to pediatric ophthalmologists.) We will do our best to avoid potential conflicts of interest among editorial board members and reviewers in more “industrially active” subspecialties. And our desire to promote lifelong learning is a salute to one of the pillars of the American Academy of Ophthalmology. But serving society requires the journal to effect “the advancement of innovation and discovery.” How should we define discovery? A vignette from Stuart Firestein's small but pithy book Ignorance offers a workable answer: “The eminent physicist Enrico Fermi told his students that an experiment that successfully proves a hypothesis is a measurement; one that doesn't is a discovery. A discovery, an uncovering—of new ignorance.”6Firestein S. Ignorance How it Drives Science. Oxford University Press, Oxford2012Google Scholar In other words, good science enables understanding, but more importantly, it evinces what we do not know. Many people avert their eyes and shuffle their feet when confronted with the paradoxical idea of desirable ignorance, but they needn't. As defined by Firestein, ignorance is “… a communal gap in knowledge. It is a case where data don't exist, or more commonly, where the existing data don't make sense, don't add up to a coherent explanation, cannot be used to make a prediction or statement about some thing or event. This is knowledgeable ignorance, perceptive ignorance, insightful ignorance. It leads us to frame better questions, the first step to getting better answers. It is the most important resource we scientists have, and using it correctly is the most important thing a scientist does. James Clerk Maxwell, perhaps the greatest physicist between Newton and Einstein, advises that “Thoroughly conscious ignorance is the prelude to every real advance in science.'”6Firestein S. Ignorance How it Drives Science. Oxford University Press, Oxford2012Google Scholar Returning to John Adams and his “stubborn facts,” in 1770 his perspective, most likely, was that objective, verifiable, and seemingly unambiguous events or eyewitness accounts were beyond refutation. In the 21st century, however, post-Einstein, we see the world more conditionally. Firestein again: “… all scientists know that it is facts that are unreliable. No datum is safe from the next generation of scientists with the next generation of tools.”6Firestein S. Ignorance How it Drives Science. Oxford University Press, Oxford2012Google Scholar Taking this idea even further, the insightful medical historian Jacalyn Duffin has commented that “[f]or postmodern scholars, progress, like facts, may no longer exist. Progress, in the sense of desirable improvement, is certainly problematic when those doing the labeling are also its proponents. We can be curious about the present without believing in its immutable superiority.”7Duffin J. History of Medicine.in: A Scandalously Short Introduction. University of Toronto Press, Toronto1999: 374Google Scholar Well, yes and no. Facts surely can be stubborn, and much about the present is immutably vexing, but progress does seem to occur. Compared with 50 years ago, far fewer orbits are exenterated for rhabdomyosarcoma, fewer eyes are enucleated for retinoblastoma, and it is the rare patient who spends a night in the hospital after cataract surgery. For patients, these arguments and outcomes are not academic. Facts change—thankfully—and thus knowledge increases. Now, I admittedly make that assertion with caution, or at least with less confidence than if I had not veered to dip my toe in the waters of epistemology. As every physician knows, what is regarded as truth in medicine may vacillate wildly over 50 years, and I was curious to learn that 2013 marks the 50th anniversary of a sea change in the study and theory of knowledge. Briefly, in 1963, Edmund Gettier published a concise paper in which he challenged a philosophical tenet that had been widely accepted for centuries, namely, that the nexus of “justified true belief” meets the criteria for “knowledge.”8Gettier Edmund L. Is Justified True Belief Knowledge?.http://www.ditext.com/gettier/gettier.htmlGoogle Scholar Gettier's proposition was illustrated by 2 vignettes or “thought experiments” that seemed to demonstrate the fallacy of this axiom. Naturally, this has led to an extensive literature of hypothetical counterexamples and counter-counterexamples, many taking into account the possible confounding effects and biases of culture, language, and even genetics. For this reader, the explanations are interesting, but far more difficult to follow than determining the cause of unusual vertical strabismus in a patient with a head tilt, torticollis, blepharoptosis, and photophobia. With renewed respect for Alfred Bielschowsky and gratitude that I am a physician and not a metaphysician, it occurred to me that we have a ready metaphor to remind us of the limitations of what we can know and what we can do: the circle of least confusion. Most lay persons believe that light is focused “on the retina,” perhaps in part because that's how we usually describe optics to our patients. But of course we know (uh oh: there's the k-word again …) that incident light rays passing through an astigmatic lens result in a conoid of Sturm and not a focal point. The circle of least confusion—marvelously named—is imperfect, but it works satisfactorily for our visual needs. Recognizing that medical research is unlikely to achieve pinpoint accuracy, perhaps striving for the “least confusion” can serve as a realistic goal for investigators and for those of us who have the responsibility of publishing their work. The evolutionary biologist Mark Pagel wisely stated that “[t]he elusive nature of knowledge should remind us to be humble when interpreting it and acting on it, and this should grant us both a tolerance and skepticism toward others and their interpretations. Knowledge should always be treated as a hypothesis.”9Pagel M. Knowledge as a hypothesis.in: Brockman J. This Will Make You Smarter. HarperCollins, New York2012: 341Google Scholar Tolerance, skepticism, and humility—these are useful attitudes as we approach the challenge of embracing ignorance, and then redeeming it for the benefit of our patients. Thoughts on Skills and KnowledgeOphthalmologyVol. 121Issue 1PreviewRelated to Dr Bartley's editorial on ignorance, epistemology, and the circle of least confusion,1 I wish to share how the concept of useful ignorance can be applied to the 4 stages of skill acquisition. As taught to me by my father, the stages are unconscious incompetence, conscious incompetence, conscious competence, and, finally, unconscious competence. We cannot learn to do something without first becoming aware (sometimes painfully so) that we are unable to perform what otherwise looks like a doable task. Full-Text PDF
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