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The Stages of Knowing

A while back I was introduced to a concept called ‘the stages of knowing.’ These three stages are based on the work of Dr. William Perry. It was broken down into three stages.

Stage One: The Garden of Eden

Stage Two: Anything Goes

Stages Three: Thinking Critically

I started to think about what stage most emergency providers fall into. I came to realize the answer really involves how much emphasis providers place on their education (and I don’t just mean during school). Much of getting through these stages involves active learning after school. I also came to realize we are not on the same level of knowing for all areas. You can’t just say: ‘that person is at level one’ and ‘that person is at level 3.’ It doesn’t work that way. We may have ‘critical thinking’ ability (level three) when it comes to some things, but only a ‘Garden of Eden’ (level one) understanding in others. What do the levels mean? And how can we use our understanding of them to our advantage?

Stage 1: The Garden of Eden

In stage one, we know something to be true because authorities told us it is fact. In medicine, this can be compared to someone like a professor telling us some piece of information, and us taking that piece of information at face value (believing it just because our professor told us it’s true). At different stages in our life we have different “authorities” that we believe in, and take their words as absolute truth. As children, we believe our parents are infallible. Later on in life we may come to believe that certain professors, public figures, etc. are also infallible. Why is this stage one? And what is so wrong with this way of thinking?

An ancient proverb says : ‘A simpleton believes every word, but a shrewd man considers his steps.’ What does this mean? It means no human is infallible, and we are fools to believe that they do not make mistakes in word and deed. We should always be proving things to ourselves, not just blindly accepting everything as fact. How does this apply in medicine?

In medicine, we have the abilities to make huge, astronomical, life changing decisions for our patients that can change their life course from that moment on. Think I’m going a little overboard with that statement? Consider a Resuscitation Sequence Intubation, a code, hemorrhage control, managing electrolyte replacement, caring for a respiratory emergency, or spotting a STEMI. Now imagine one of those things goes terribly wrong because someone in the chain of care of that patient has bad information. Imagine someone who’s superior once told them:

Resuscitation Sequence Intubation: 'preOx and nitrogen washout doesn’t matter. Just get the tube in fast.'

Code: 'Give it 20 minutes and call it'

Managing electrolyte replacement: 'Get their sugar down as quick as possible.'

STEMI: 'You can’t see a STEMI if they have LBBB/Pacer/LVH'

Vent management: 'Just put adults at 500/12/5/100%'

Soft skills: 'If it’s just suicidal ideation, they can drive themselves to the specialty hospital'

These are dangerous and misleading statements that will likely cause a patient permanent organ damage or death. What is worse, these were all things I’ve heard from practitioners in teaching roles. I’ve been guilty myself of telling providers something that I was SURE was true, only to find out later that I had just been handed down bad information earlier in my career that I had held onto. What is the take home point? Just because someone is a professor, attending, FTO, or any other ‘authority’, this does not mean they are always right. Be cautious of what you believe, and always check that facts. What about stage two of knowing?

Stage 2: Anything Goes

I find that stage two is the hardest to get providers out of. Once they move past stage one and realize that the authorities do not have all the answers, they enter stage two. In stage two, they believe no one has the answers, so it doesn’t even matter what they do. This stage comes with a certain apathy. Clinicians feel like it isn’t even worth looking for the answers. The providers conclude: ‘If the authorities can’t figure it out, how will I?’ It is hard to gain a providers trust at this stage and get them to look into evidence based medicine. These people are rather easy to spot. When discussing treatment modalities with them, you will see them express doubt on their face, conveying feelings of uncertainty about anything you have to say. They will then often shed doubt on whatever you say, and shrug their shoulders when presented with evidence. Sound familiar? How do you get someone, or yourself, out of stage two?

To get out of stage two you have to be open to the fact that some ways of doing something are better than others. If you can believe that statement, you have the capability to leave stage two. The next step is to carefully consider which authorities you will begin to evaluate. Know that you don’t have to believe these authorities when you listen to them, read their words, or watch them perform. Just know that you have the ability to decide for yourself if what they are teaching is measurably beneficial in some way. Let’s look at the same examples as before and see how people's minds might start to change.

Resuscitation Sequence Intubation: 'I didn’t know you could have so much of a longer safe apnea period with nitrogen washout, good PreOx, and ApOx'

Code: 'CPR is just organ support? Sound like might need to think a little harder to find the reversible cause…'

Managing electrolyte replacement: 'That’s interesting, I didn’t know about the roles of glucose and cerebral edema and seizure'

STEMI: 'Smith Modified Sgarbossa criteria? I wonder what the studies show'

Vent management: 'PETALNET? I wonder why that matters'

Soft Skills: 'I cannot believe that some patients never made it to definitive treatment on their own'

Stage Three: Critical Thinking

In stage three, we move past the “anything goes” attitude and decide that some ways of caring for patients are in fact better than others. We always knew this to be true, but we didn’t trust this fact enough to actively seek out better ways. You can recognize this in providers very easily. When asked why they performed a task a certain way, they will likely respond with very sound reasons as to why. Perhaps they have personal experience in trying different modalities, have done extensive research on best practices, or ideally a combination of both. Part of critical thinking is the ability to objectively evaluate authoritative sources and make an informed decision on how you will change your practice for the better. I always encourage providers to stop and think about the decisions they made over the course of a shift, and just pick a few. Did they make those decisions just because that was the way they were taught in school, or have they really proven it to themselves that their current practice is the best way to do things? In this stage, open-mindedness is important. Why?

In medicine, things are always changing. We may have just come up to speed on some treatment modalities, and then things change again. ‘I just learned about the last thing and now it’s out of date???’ We may also become overly accustomed to a certain way of doing things, and who can blame us? We are creatures of habit, and it can be hard to change habits. However, we must be willing to break out of our comfort zone, a least once in a while. This requires an open mindset. What will an open mindset do for us?

When an open-mind is confronted with new information, it’s immediate reaction is something like: “I wonder how I can find out if that is true or not.” Conversely, when a closed-mind is presented with new information it will likely immediately think: “Nope, I don’t think so” / “That’s stupid.” This is an easy trap to fall into, especially if we fancy ourselves informed patient advocates. Most of us have probably had the experience where a brand new prover tells us something, we wrongly dismiss it, only to find out later that they were 100% correct. We can start to avoid this type of embarrassment if we just train our brain to ask: “I wonder if that’s true,” rather than “that’s wrong.” Don’t believe me? Good! Prove it to yourself. ;)

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