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“Ignorance has no place in medical schools and hospitals:
Down with Agnotology!”
Melchor Sánchez MD, MHPE, PhDUNAM Faculty of Medicine, Mexico
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Do you know in what is Mexicothe world leader?
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a) Food (tacos)
b) Corruption
c) Tourism spots
d) Drug traffic
e) Adult jokes
f) Educational innovation
g) None of the above
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http://thedoghousediaries.com/5414
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Learning objectives
To reflect on the concepts of agnotology, ignorance, doubt and uncertainty and their role in clinical medicine.
To identify your feelings about these concepts as a clinician, educator and human being.
To discuss potential approaches to teach agnotology, uncertainty, ignorance and doubt in healthcare settings.
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8
“Medicine is a science of uncertainty and an
art of probability”- William Osler
“Doubt is an uncomfortable condition,but certainty is a ridiculous one”
- Voltaire
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10
“… The failure to trainappropriately studentsfor clinical uncertainty,
has been the mostimportant deficiency of
medical education in the
20th century...”
Kenneth M. Ludmerer. Time to Heal.Oxford University Press, 1999
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www.nytimes.com/2015/08/24/opinion/the-case-for-teaching-ignorance.html?_r=1
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Session overview…
Personal and group views on the subject
What is agnotology?
Implications in medical education
Conclusions and reflections…
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Who said this?
“All I know is that I know nothing”
a) Socrates
b) Plato
c) D. Trump
d) Don’t know
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“…as we know, there are known knowns; there are things we know we know. We also know there are
known unknowns; that is to say we know there are some things we do not
know. But there are also unknown unknowns – the
ones we don't know we don't know”.
Donald Rumsfeld
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https://en.wikipedia.org/wiki/The_Book_of_General_Ignorance
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What is…?
Ignorance
Uncertainty
Agnotology
From your perspective as…a person/human beinga professionalan educator
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Group discussion
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Han KJ et al. (2011). Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making, 31(6):828–838.
Uncertainty: situation which involves imperfectand/or unknown information (Wikipedia).
Subtly different in many fields: insurance, philosophy, physics, statistics, economics, finance, psychology, sociology, engineering, metrology, and information science.
Uncertainty: “the subjective perception of ignorance”.
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Agnotology: the study of culturally induced
ignorance or doubt, particularly the publication
of inaccurate or misleading scientific data.
Neologism coined by Robert N. Proctor,
Stanford professor of history of science.
https://en.wikipedia.org/wiki/Agnotology
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Derives from Greek agnōsis , “not knowing”.
The term also highlights the increasingly
common condition where more knowledge of a
subject leaves one more uncertain than before.
https://en.wikipedia.org/wiki/Agnotology
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http://www.sup.org/books/title/?id=11232
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https://www.routledge.com/Routledge-International-Handbook-of-Ignorance-Studies/Gross-McGoey/p/book/9780415718967
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Taxonomy of ignorance1) As primitive or native state: most common; prompt
for knowledge; implies deficit; e.g. grant application:
“We know this but not yet this - so fund me please!”
2) As lost realm (or selective choice): political
geography, inquiry is selective; “a way of seeing is also
a way of not seeing”; e.g. peer review process.
3) As deliberately engineered and strategic ploy:
intentional maintenance of ignorance; trade secrets;
e.g. tobacco industry (“doubt is our product”); WMD.
Proctor RN. Agnotology. SUP. 2008
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http://onlinelibrary.wiley.com/doi/10.1111/nyas.1995.775.issue-1/issuetoc
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How can we teach health sciences students (and teachers) to deal with ignorance, uncertainty and doubt?
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Group discussion
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A curriculum on medical ignorance
Multifaceted curriculum on medical ignorance.
Questioning seminars, clinical and laboratoryexperiences.
Attitudes and behaviors to deal constructivelywith medical ignorance and the limitations of “knowledge of the day”.
Prepare for uncertainty in practice.
Witte MH et al. Med Educ 1989; 23:24-9.
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Witte MH et al. Med Educ 1989; 23:24-9.
Curriculum components
Seminars and Clinics on Medical Ignorance.
Summer Institute on Medical Ignorance.
“Visiting Professors of Ignorance”.
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http://ignorance.medicine.arizona.edu/
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https://www.harpercollins.com/9780062374349/this-idea-must-die
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“What you do speaks so loudly
that I cannot hearwhat you say”
Ralph Waldo Emerson
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Sources of complexity in clinical decision making
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Used in 29 Mexican schools. 22 Medical. 3 Nursing. 1 Veterinary. 1 Physiotherapy. 1 Odontology. 1 Nutrition.
Sánchez M, Martínez AI, Eds. UNAM. ELSEVIER. 2a Edición. 2014.
ISBN: 978-607-02-4985-3.
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Conceptual model
Hamui-Sutton A, Vives-Varela T, Gutiérrez-Barreto S, Leenen I, Sánchez-Mendiola M.BMC Medical Education 2015, 15:198 DOI: 10.1186/s12909-015-0459-2
A typology of uncertainty derived from an analysis of critical incidents in medical residents: A mixed methods study
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Probability of being in a situation of uncertainty
Communicational
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Probability of being in a situation of uncertainty
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Strategies used by type of uncertainty
52
Consulted with peers or colleagues
with a lower academic level
Communicational
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“It was the best of times,
It was the worst of times…”
Tale of Two Cities
Charles Dickens
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