“It's better to be smart than dumb” or the clinical importance of ignorance

Abstract

I n the course of clinical teaching, it is not unusual to preserve and propagate maxims: pithy, usually practical guides for intellectual, medical, and personal conduct. We know them as “pearls.” We joke about pearls. We drop them. We covet them the way a poet relishes a succinct sonorous rhyme. They are the haiku of medicine. Their influence is sometimes in excess of their validity. It is usually true that “you never see a fat pheo,” but “never” is a word too precise for clinical medicine. Medical pearls may be misapplied to circumstances outside the clinical arena. “The patient always comes first” is turning out not to be a totally supportable political or economic principle. After 20 years of rounding and lecturing, I have accumulated some of my own pearls. I would like to examine one of these maxims in the light of some of medicine’s contemporary dilemmas. Lee’s first rule states that it is better to be smart than dumb. This scholiurn used to be infrequently required, but lately I find myself using it more and more. And I find myself increasingly curious about the need to repetitively emphasize what seems to be so obviously pertinent to medicine. The answer is to be found, in part, in two ancient, seemingly inimical notions that have reentered a cycle of popularity and influence during the past few years: economic realism and mystical medicine. Ever since bipedal primates became self-conscious and aware of their individual aloneness, humankind has had to deal with illness, pain, and death as more than a fact of life. Explanations and remedies had to be explored and constructed, as much for social solace as for individual restoration. The idea that the quality of life determines the course of individual human existence is the fundamental concern of mystical medicine: disease and damnation are the inexorable consequence of debauchery and deviation. Illness can be produced by social and spiritual malfeasance as well as by biologic malfunction. Dietary, dialectic, and devotional rules and rituals have been created to prevent and to repair the baleful effects of bad thoughts, bad living, bad spirits, and bad biology. The liturgies and rites of the world’s religions contain elements of mystical medicine.