Debriefing missions and training iterations is standard practice among military and law enforcement special mission units. Despite the best efforts of everybody involved, communication is an issue that consistently emerges as a limiting factor in operational performance. During complex missions, leaders must filter a continuous stream of information from multiple sources to optimize decision-making. The information is usually incomplete because the messengers are either too preoccupied with fulfilling their individual responsibilities (e.g. a medic attempting to stabilize a casualty) or too far removed from the reality on the ground. During tactical scenarios, information must be communicated succinctly but sufficiently thorough to be of value. These qualities are often at odds, especially when one considers the propensity for communications technology to fail at the least opportune times.
Communication can also be a limiting factor in medicine even for technically competent providers. In medicine, communication occurs in various domains but the popular narrative tends to focus on the interaction between the provider and the patient. Medical providers are becoming more careful about how they deliver a message to a patient. In many cases, sound medical practice involves some type of behavioral modification from the patient, even if it’s something as uncomplicated as ingesting a medication a few times a day. Behavioral change, no matter how seemingly simple, can be threatening. Consequently, medical providers are careful to deliver messages in theoretically robust, non-threatening ways to mitigate the potential for the patient to resist behavioral change.
Progressive chronic pain practitioners are especially adept at delivering their messages responsibly. This community in particular emphasizes the influence of diction on symptom presentation. Many medical providers still say things like “you have an exploded disc in your back” or “you’re 35 but you have a 70 year old knee”. Based on what we now know about pain science, this manner of communication is simply not good medicine. The delivery of a message matters because it can actually dictate outcomes, clinical ones in this instance. Unfortunately, people often fail to apply this lesson when they communicate amongst their peers, especially in online forums.
Replace historical theories with Pubmed citations
The conversation between Ben Affleck’s character and the pony-tailed graduate student is a microcosm for how many medical practitioners interact with one another. Scientific data is increasing as rapidly as the knowledge disparity among different providers. In most professional discussions, it is clear that the participants value research studies, theoretical plausibility, and clinical experience to different relative degrees. In an ideal world, the continuity among the various pillars of evidenced based medicine would be seamless. In practice, however, there is a gap to be bridged between academic and clinical medicine. Navigating this divide and advancing the practice of medicine requires intellectually honest and respectful dialogue.
In medicine, theoretical soundness is more of a relative than an absolute phenomenon. Consequently, the medical equivalent of the pony-tailed character above should convey his superior knowledge with more humility and tact. His manner of speaking places the recipient of the message on the defensive and effectively ends any potential for meaningful conversation. He is more concerned with demonstrating his superiority than he is in advancing a discussion about history.
Highly educated people often counter that tone shouldn’t matter if the message is credible. That would be true if professional debates were logic proofs and not human interactions. As pain science researchers have demonstrated, the delivery of a message can be just as impactful as the message itself; poor delivery can undermine an otherwise sound message. In other words, conversational etiquette applies to other providers just as it does to patients. The burden is more so on messengers to be decent than it is for recipients to be thick-skinned, especially when it cannot be demonstrated that a callously delivered message leads to superior professional outcomes. It is fairer to say that poorly delivered messages adversely affect outcomes.
Respectful, intellectually honest conversation requires context. Well-conducted studies control for the effect of context on a particular outcome measure. This reductionism is a necessary aspect of the scientific method, one that does not necessarily diminish its utility. Research studies, therefore, provide the dots that must be connected by rational thought and professional collaboration. The increasingly prevalent practice of posting peripherally relevant Pubmed links without any qualification in a “drop the mic” fashion during online medical discussions is an intellectually dishonest debasement of evidence-based medicine. It’s no different than regurgitating history book passages in a bar to impress a potential romantic partner; without context, such passages are meaningless. Professionals owe one another more than that.
Conversations that advance professions should be difficult, tedious, and contentious. Conversations can be contentious without being overridden by emotion. In professional conversation, one is less likely to lose sight of the intent when he/she isn’t concerned with being “right”, but with making a reasonable case. Making a reasonable case is process driven. Attempting to prove someone wrong is outcome driven. Some people cannot be swayed by reason and theoretical precision. They should not be ridiculed into changing their minds as often occurs after civility proves unsuccessful. Fixating on winning the argument personalizes the discussion at the expense of professional growth. The evidence doesn’t always speak for itself but respectful dialogue encourages one’s colleagues to engage in future discussions during which they may be more willing to entertain new ideas. We can all learn from Bill, Ted, and Socrates’ excellent adventure during which they concluded, “The only true wisdom lies in knowing that you know nothing.” The advancement of knowledge requires humility.
The greatest historians of our generation…