The Knowledge Paradox

There are plenty of confusing and seemingly counterintuitive things in health that people, or the health professionals helping them with their issues, have to navigate.

Things that are painful aren’t always bad for you. 

The food that tastes the best is probably killing you slowly.

The path that seems the hardest is probably the best one for you.

One of the most paradoxical things I have come across is more to do with myself. And, in my non humble opinion, is the thing that separates expert clinicians from non. Or, in Dave’s language, it separates the people that you should listen to from the ones with heads firmly up their arses.

It can be summarised in 2 sentences.

1. Conditional on having some knowledge in a field, knowing the limits of this knowledge is more important than acquiring more.
2. It is easier to be confident in a course of action when your knowledge in the area does not contain an understanding of its limits.

In other words, the more overconfident and infallible you feel, the more likely you are to transfer this ill-founded confidence of certainty onto the people who ask you for help.

Conversely, having a healthy dose of humility and more closely understanding the reality you exist in can make it harder to convey the reasons, at least in the short term, why someone should follow your recommended course of action.

This is what I call the knowledge paradox.

• The ones to listen to are often the ones you tend not to listen to

Knowledge is fuzzy.

How we know what we know and how confident we should be in what we know has been keeping philosophy professors in jobs for centuries.

That’s not really what we are going into here, as tweed jackets and pipes aren’t really my thing.

As a clinician first and foremost I'm interested in action rather than discussion.

However, a lot of what I do is talking to someone about what they should do for their pain and injury and why, so knowing my shit is a big part of the job. 

Health professionals are all smart (some of them make it hard to believe, I know). It’s not that they don’t know stuff. They know lots of stuff. It’s more that they don’t know when they have moved past what they know into what they don’t. Or that they can’t tell the difference between the areas they should be confident in and the areas they should be cautious about.

There are 2 reasons for this.

We are all overconfident in how much we know. We all think we know more than we do.

Really.

And because pain and injury are weird, lots of things get better for all sorts of reasons, so every health professional will help some people no matter what they do, even if they rub peanut butter into their skin while sniffing peppermint oil and listening to Enya.

The ones that don’t get better go somewhere else, and fall out of our view.

So we also think we are pretty fucking good at peanut butter rubs (or whatever).

Particularly in pain and injury, things can change. Not rapidly evolving, paradigm shifting jumps every week. But things are fluid. Realising that our grasp on what we do is in constant need of rechecking, it is much harder to continue to evolve what you do as this knowledge changes.

Changing what you do, when your income depends on you doing it, is very hard.

You can see plenty of health professionals that got very good at what they do in a certain part of space and time.They become successful and respected.

Then space/time moves.

Letting go of what made you successful to move towards things you are less sure of is very difficult.

Many don’t do it.

Much easier to stick to what you know. (Or at least what you THINK you know)

The other end of this is where there is early knowledge development, but not enough to understand the limits. This is so common it was studied by psychologists who lent their name to the Dunning-Kruger Effect. Basically a mismatch in actual knowledge and CONFIDENCE in your knowledge.

This is the domain of Instagram, and the internet generally.

The downside of this common human trait, combined with the age of information, is that we confuse confidence and frequency for accuracy.

Basically, the more full of shit you are and the more people you tell how smart you are the more people start to think maybe you are right.

Meanwhile, people who have a more accurate understanding of their subject matter and the limits of their knowledge say things like “I don’t know” or “it depends” and can seem uncertain.

Well sports fans, that’s the fucking point.

We should be uncertain.

We cannot predict in complex systems.

We can however have the knowledge, skills and confidence to act depending on what transpires and update our actions based on more information.

This is how I describe what I do in pain and injury rehab.

Particularly on an individual level in terms of pain and injury, most of the time there is a gap between what a person knows about their pain and/or injury and what we currently know as our best guess as to what is going on. 

Even here is another mini paradox

What we explain to people as the truth is not an exact representation of reality.

Health care is not astrophysics. (Even that has changed over time)

In health care, “knowledge” is a best guess of what we think is going on.

ESPECIALLY with pain.

Injury and pathology we are a lot better at, as we have tests that can show us fairly accurately what is going on. Not exactly, but closer. These are very, very fallible and there is a lot of noise with these tests. But they are, at least, in existence.

Think blood tests, MRIs and Xrays.

There is no test for pain.

You cannot see it anywhere, only the effects on the person experiencing it and their description of this experience.

So, depending on who they ask, a person can hear 16000 different reasons as to why something hurts.

If you fall down the stairs and break your leg, why it hurts is more obvious. Why you fell has multiple variables, as does why it hurts as much as it does, but the basic explanation is fairly consistent across different health professionals.

Why a person has back pain, however, is a different story.

The real, accurate answer to this question, without any more information (and even then it’s probably the same answer) is - nobody knows.

But when your back hurts, this can seem like a shit answer.

Much better to blame your hip flexors, your weak glutes, your chair, your bending and lifting, your shoes and your posture.

Because we can fix that shit!!

It’s tangible, certain and actionable.

And completely fucking wrong.

So, instead of making up reasons that don’t exist, and comforting ourselves that we are so fucking smart and can fix everyone, rehab professionals need to get more comfortable with what they don’t know and focus on what they are actually good at - helping people navigate pain and injury back to what they want to do.

The upside of being uncertain is you have options.

Particularly with pain there are so many things you can do to help someone. Rather than holding on to simplified models of causation, give people accurate understanding of their individual situation and then do something!

There is often a very large discrepancy between the experience of pain, a person’s ability to do the things they want to do and the health of the relevant tissue.

When things are painful, this feels like they are all the same thing - and it’s all shit.

This is often the case, and they are closely associated and interdependent. Again the broken leg comes to mind.

But many things, most things in a person’s life by balance of probability, can hurt, but have not much, little or absolutely fucking zero to do with the health of their tissue and what they can do.

When we start to identify the gaps, it gets easier for them to do more of what they want, and guess what? Shit gets better. We don’t have to understand the black box of pain to help someone have less pain and more meaningful activity.

The problem with the knowledge paradox is that the person who is best equipped to help someone navigate these complex experiences of musculoskeletal pain is the one who sounds like maybe they don’t know.

They live in uncertainty rather than deny its existence, their statements are flexible and they build in the person’s thoughts and choices into decisions, they learn to deal with randomness rather than claim to have tamed it.

Above all, they are up front about the limits of what they know.

And, perhaps somewhat counterintuitively, this makes them much more likely to be successful.