The act of asking for information, or the process of inquiry, is not restricted to those pursuing higher education. It is basic human nature. In fact, it really is nature.
Red algae of the sea pose a neurochemical question to planktonic mollusks asking them to plant their larvae upon them yielding a symbiotic relationship (1). Plants inquire regarding the nutrient density of the soil milieu, receiving response when a chemical fits a molecular transporter on the roots or continues to pass by in the diffusing water currents (2). The embryo asks the mother if it will develop into a fetus, acknowledging its answer if it receives a molecular notch signal from the welcoming endometrium (3). A puppy pushes its bowl toward the toes of his owner and knows by smell if he will get dinner just yet. A physician reaches out her hand to meet that of a patient and in that moment has already begun to ask, “how can I help?” A group of biochemists ask how communications like these happen and find their answer in the physiology of cellular vesicular transport. If you ask how significant these communications are, you’ll find the answer in that this discovery was awarded a 2013 Nobel Prize (4).
Inquiry is ubiquitous. It is fundamental to life. Further, it is dependent on the laws of physics and chemistry. The inquisitive physician-scientist’s firing neurochemical synapses during the process of building a hypothesis or diagnosis, are reliant on the same chemicals of the red algae-mollusk relationship. Yes, gamma-amino butyric acid (also known as GABA) is the same chemical that functions to help you with the process of inquiry as to help the algae establish a viable environment1. Certainly the nature of human inquiry is exponentially more complex, but does this not suggest that, on some level, the nature of every life form is built on the basic fundamentals of inquiry? It would stand to reason that inquiry is what has allowed us to be so “fit” as to stand where we are in the course of evolution, per Darwinian theory. Our ability to question the environment around us and ask how to advance our lives and the lives of future generations has brought us to the ever-advancing 21st century. However, I would argue that it is the questions to which we have turned our cheek that have brought us the challenges of the 21st century.
Not having an answer is not the problem. In my opinion, the strongest scientific findings are those that can only be answered with further questioning. Trouble comes when we stop asking. Take environmental studies as an example. In the 21st century we certainly have found the answer to the question, “how do we attain mass production?” However, if we stick with the answers we have found to this question, we will have further environmental devastation, growing widespread global starvation, exponential greenhouse gas emissions and, eventually, a shortage of the very products we now mass supply (5). Many parallels can be drawn here to the healthcare system of the 21st century. We are most efficient at helping acutely ill patients and those with access, but we have some inquiry yet to do regarding prevention of chronic illness and helping the underserved. We have become very evolved technologically, constantly finding new tools, but we have some inquiry yet to do regarding revisiting the powerful tools of the physician; his hands. We have become very good at discovering cutting edge genetic, nanoparticle and pharmaceutical based interventions to optimize treatment, but we have some inquiring to do about prescribing basic human essentials like whole foods and real social connection (not just the kind we’ve built with these very technological advances). We have become very good at ordering laboratory and imaging tests, but we have some inquiry to do to reduce healthcare expenditure. I know what you’re thinking and you’re correct; these advances are life changing, essential and damn right fascinating and no, we wouldn’t have known of these potential problems without having sought out these answers to begin with. I am not by any means implying the future questions deplete the significance of the existing examples of progresses collectively made by the human race. In fact, I believe no judgment should ever be made of any “question or answer”. Didn’t a teacher once tell each of us there was no such thing as a bad question? Rather, I suggest we shift mindfully onto each novel question the moment it reveals itself. The question, generally speaking, is, “how can we improve upon this answer?” Now, I regret to say I cannot take credit for this as if it is some groundbreaking and novel concept. Voltaire states, “Judge a man by his questions rather than his answers” and Einstein said, “The important thing is not to stop questioning. Curiosity has its own reason for existing”. Evolution of man and his quest for knowledge is not based on the swiftness of reaching the right answer. In fact, is the eternal question of mankind not, “what is the purpose and meaning of life?” Perhaps no right answer exists because of the fleeting experience of environmental change as a result of the ever so awe inspiring transient mechanisms of the fundamental basic sciences yielding the evolution of life, the planet and potentially, the universe.
Two things we have for sure are the moment, and our ability to inquire within it. We live by this concept, so let me say it again. We only have the moment and our ability to inquire within it. Imagine a world where we truly lived by this. Imagine a healthcare system where we truly practiced medicine by this. Now that is evidence-based medicine in its essence. Of course, it is fairly obvious that the fundamentals of the art of medicine are based on inquiry. We are trained how to, “think like doctors” which entails applying our collection of knowledge and skills to answer a clinical question before us in the form of a patient. This, which can be found in some way traced back to the very first documentations of healing, is truly one of the purest examples of the art of inquiry that exists within the human race. It may not have always been through randomized placebo controlled clinical trials, but every “healer” inquired to their patient’s condition, to what approach to take to facilitate healing and to see if it the approach was successful. Regardless of outcome, there is a need to repeat the inquisitive process from step 1 either with the current condition and patient or the next. This is The Scientific Method. Yes, capitalized. It lives in the nature of those whom chose a healing path.
The art of inquiry in medicine is much deeper than this simplification lends us to believe. Let’s pose a scenario, based in modern clinical practice such as an emergency room. Doctor A walks into a patient room, greets the patient with a handshake, sits down and inquires about the arm. The patient anxiously states, “my shoulder was dislocated”. Doctor A asks how and the patient hesitates to explain that, “it just happens sometimes.” The doctor standing at her side explains to the patient that it is an easy fix while performing a joint reduction, flawlessly, before the patient has time to react. Doctor A suggests follow up, especially given the frequency of recurrence, and leaves the nurse to lend a hand for the rest of her recovery while breaking before the next patient. Doctor B walks into the same scenario. However, the first words of Doctor B are, “how are you doing?” The patient’s eyes well with tears and then a mumble is produced, “not well”. Doctor B acknowledges the tears and asks, “what’s going on?” The patient replies, “my shoulder was dislocated”. Doctor B asks how and the patient hesitates to explains that, “it just happens sometimes.” Doctor B, similar to Doctor A, completes the reduction, instructs the patient’s care and leaves the room. However, after the next patient, Doctor B returns to follow-up. At this time the doctor proceeds to inquire about the word choice of the patient, which seemed to externalize the injury and asks for details regarding the prior injuries. Through this process the patient timidly reveals a history of an abusive relationship. Both Doctor A and B demonstrate approachable bedside manor and flawless clinical skills. However, Doctor B chose to invest a bit more on inquiry ultimately uncovering the root of the problem that would likely go otherwise unnoticed (6).
Insert into this fictionally sculptured scenario whichever variable you have encountered. Perhaps you can imagine a time where the one more question asked, either of the patient or of a clinical assessment, leads to the confirmation of an otherwise missed diagnosis of a rare disease. Imagine a scenario where acting on the inclination to ask a patient about spiritual, coping and support systems results in a strengthened patient-doctor relationship (7). Imagine allowing a patient to ask his or her own questions leading to improved encounter satisfaction (8). Imagine an open-minded application of scientific inquiry to understanding an alternative treatment modality a patient admits to using leading to enhanced evidence-based practice. Imagine such a modality, or the simple word choice of a clinician to use “comfort” rather than “pain”, harnessing the placebo response to bring improvement to a patient that otherwise would be in a state of chronic pain or dysfunction (9–11). Imagine the simplicity of the non-verbal assuring smile with an open posture suggestive of active listening and the physician’s commitment to inquiring further on behalf of the patient and their state of health leading to trust and serene relief of the patient. Regardless of the scenario, the ideal physician exercises the art of inquiry through open-minded scientific method, clinical skills and good old fashion bedside manor.
– Things learned from a medical student research fellow at the National Institutes of Health –
There are no great secrets of inquisition kept at the NIH. Well, other than a few potentially life-changing discoveries locked behind the walls of pending grant funding and patent approvals. In fact, physicians and scientists here, despite being immersed in hypotheses for a living, can just as easily miss opportunities to inquire further. However, if one’s constantly open to their inquisitive nature, whether that be of a naïve physician-scientist trainee at the NIH or algae of the seas and roots of the trees, the moment will only beg you to ask… quite literally. So I pose to you, how will you use your inquisitive nature, in this moment, to propel the evolution of humanity to a healthier place?
References:
1. Shelp BJ, Bown AW, Faure D. Extracellular γ-Aminobutyrate Mediates Communication between Plants and Other Organisms. Plant Physiol. 2006;142(4):1350–1352.
2. Claassen N, Barber SA. A Method for Characterizing the Relation between Nutrient Concentration and Flux into Roots of Intact Plants. Plant Physiol. 1974;54(4):564–568.
3. Cuman C, Menkhorst EM, Winship AL, et al. Fetal-maternal communication: The role of Notch signalling in embryo implantation. Reproduction. 2013.
4. Nobel Prize in Physiology and Medicine 2013, report. Available at: http://www.nobelprize.org/nobel_prizes/medicine/laureates/2013/press.html.
5. Foley JA. Sustainability: Can we feed the world and sustain the planet? Scientific American. 2011:60–65.
6. Beynon CE, Gutmanis IA, Tutty LM, Wathen CN, MacMillan HL. Why physicians and nurses ask (or don’t) about partner violence: a qualitative analysis. BMC Public Health. 2012;12:473.
7. Hebert RS, Jenckes MW, Ford DE, O’Connor DR, Cooper LA. Patient Perspectives on Spirituality and the Patient-physician Relationship. J Gen Intern Med. 2001;16(10):685–692.
8. Michalopoulou G, Falzarano P, Arfken C, Rosenberg D. Implementing Ask Me 3 to improve African American patient satisfaction and perceptions of physician cultural competency. J Cult Divers. 2010;17(2):62–67.
9. Fent R, Rosemann T, Fassler M, Senn O, Huber CA. The use of pure and impure placebo interventions in primary care – a qualitative approach. BMC Fam Pract. 2011;12:11.
10. Hull SC, Colloca L, Avins A, et al. Patients’ attitudes about the use of placebo treatments: telephone survey. BMJ. 2013;347:f3757.
11. Bishop FL, Jacobson EE, Shaw JR, Kaptchuk TJ. Scientific tools, fake treatments, or triggers for psychological healing: How clinical trial participants conceptualise placebos. Soc Sci Med. 2012;74(5):767–774.
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