As a clinician, how you practice is informed by your beliefs and by your sense of what is true. Your perspective is based on many factors, including your knowledge of research findings, as well as your personal experience, data you get from the physical exam and diagnostic testing, and even your gut feelings. You need to feel that a Personal Health Plan (PHP) is realistic, safe, and keeping in with your medical expertise.
Patients have their own explanations for what is happening to them and why. It is not unusual for patients perspectives to be influenced by different ways of knowing than their clinicians. They may believe they need a test or therapy because it worked for a relative, or because a television commercial said, Ask your doctor about… Perhaps they want a treatment because it worked for them in the past, or they are intuitively drawn from it. Maybe a medically-trained friend or relative told them to ask you about something. Perhaps they are making health decisions based on their religious beliefs, or their cultural backgrounds, or something they saw on the Internet (and this information may be very evidence-informed, or it may not).
The question becomes, how do you and your patients develop a PHP that honors both of your perspectives and that you both feel good about?
Mindful Awareness Moment
Something True for You
Take a moment to think of a belief you hold to be true. It can be as simple as The sky is blue or Never mess with the pancreas during abdominal surgery. It can also be something more complex, such as, I believe in an afterlife or I care about that person.
Now, ask yourself what is the basis for your belief. In other words, how do you know this belief is true?
To illustrate, lets say you hold it to be true that High cholesterol levels are bad for your heart. How do you know that for certain? There are many potential answers. You might know it because you did research yourself to verify this. You may have been told by an authority on the subject. Or perhaps you heard it on television. You may have experienced it firsthand, because you had high cholesterol and then developed heart problems.
The goal of this exercise is to get you thinking about all the possible ways there are to know something. Try it with a few other beliefs you have. Do you see a pattern related to the ways of knowing that you use the most?
Are there any ways of knowing that you would never use to decide what is true for you?
Different Ways of Knowing
There are many sources of knowledge. These include:
Facts and figures. Measurements, numbers, statistics. This can include reading the statistical findings presented in evidence-based research.
Observation, empirical thought. You see patterns or take direct measurements yourself. You learn through your own senses. The scientific method is built on this approach.
Experience. You have experienced something as true in the past. We all have those I have been burned by this before experiences that inform how we practice. Anecdotal evidence may not be valued from an evidence-based medicine perspective, but it certainly has its appeal. Consider all the websites that are selling health products. Nearly all of them feature anecdotes much more prominently that scientific research.
Hands-on learning (heuristics) is another way to gather information. I know this is how I want to place this suture, because it was how I learned to do it.
Learning from others. This one is important, especially in this era of globalization. One needs only turn do a web search or turn on the TV to get hundreds or thousands – of opinions from other people. Sources include:
- Books, education
- Media and advertising (Ask your doctor about)
Social affiliations. Much of what we know as truth is informed by the people we encounter, be it family members, friends, co-workers, or people who belong to the same club or go to the same church. Culture, too, has a substantial impact on what we believe to be true. So does tradition (hermeneutics). There are many culturally-based illnesses problems unique to specific societies or groups of people. (To learn more, start by checking out culture-bound syndrome on Wikipedia)
Narratives and art. Story is powerful for us. To learn more about the impact of story and its role in healing, refer to Narrative Medicine. People throughout history have passed down myths, stories, and histories to inform future generations.
Instinct and personality. I cant explain it. I just know because of who I am. Instinct, as we know from the natural world, is a powerful source of information.
Intuition, inspiration. While perhaps valued less in conventional medicine, these ways of knowing inform The Art of Medicine. Most clinicians have made a diagnosis or suggested a therapy just because I had a feeling it would work. And it often does.
Serendipity, chance, luck. Alexander Fleming learned that penicillin killed bacteria in part because of chance.
Collective consciousness. Is it possible for information to be understood by an entire group if one member of the group develops knowledge? Many people, including Carl Jung, have held that this is a way that understanding can spread.
In some cultures, this constitutes a very important source of knowledge.
Contemplation, reflection. Many people find that mindful awareness and intentional, focused reflection, using whatever method or tradition suits them best, can enhance understanding. See the Mindful Awareness overview for more information.
An important, and often intensely personal, means for understanding. See the Spirit & Soul overview for more on this topic.
WHY EPISTEMOLOGY MATTERS
Epistemology is a branch of philosophical inquiry which deals with knowledge and justified belief.For the purposes of this Whole Health tool, it can be defined, very simply, as the study of how we know something is true. It is helpful to think about as you co-create PHPs with Veterans, especially when there are differences of opinion about where to focus the plan or how best to achieve a goal. These moments, where different perspectives collide, are known as epistemological clashes. How successfully you can navigate these differences in perspective will have an effect on the quality of your therapeutic relationships, their satisfaction with the visit, and how well they adhere to the plan you co-create with them. All of these factors can affect patient outcomes.
Mindful Awareness Moment
Think of a recent experience where you and a patient did not see eye-to-eye on a specific topic.
- How did perspectives differ? What ways of knowing informed your point of view? What informed theirs?
- How did you handle the situation?
- What emotions or physical sensations did you experience during this interaction?
- What was the outcome?
- What would you do differently next time? What worked well?
Here are some examples of epistemological clashes that might arise in day-to-day practice:
- A Veteran refuses a blood transfusion on religious grounds, but her doctor feels it is potentially life-saving.
- A psychologist believes a patient is having hallucinations, but the patient feels he is seeing energy fields around people.
- A patient asks a nurse practitioner for a treatment for Candida that has spread throughout her body, but the nurse practitioner feels she is experiencing anxiety.
- An elderly man demands an expensive battery of tests he read about in a magazine that came to him in the mail, but the hospital team during rounds does not feel testing is necessary.
- A patient asks for acupuncture rather than general anesthesia for pain control.
- A woman wants an extended course of antibiotics because a non-VA clinician told her she has chronic Lyme disease. Her infectious disease consultant disagrees.
In most cases, these clashes of perspective arise around the following:
- What the diagnosis is or how best to make it.
- What therapy is best for a given situation. Sometimes, a clinician will support a more conventional therapy while a patient prefers a complementary approach.
- When a treatment should occur. People differ in terms of how they triage problems.
- Whether or not a patient will have a recommended screening test.
- Differences in opinion around how accessible or available a clinician or health care team should be.
How to Work With Conflicting Belief Systems
Make certain you have a good understanding of their perspective. Consider asking questions that begin as follows:
- Where did you get your information about that?
- What do you believe will happen if
- Tell me more about why you believe that…
Reflect back to them your understanding of their beliefs. Carry the belief to its natural conclusion. For example, if someone is demanding a specific test, what does he or she expect to have happen next, if the test is positive?
Be sure you have a good understanding of your own perspectives as well. It can be helpful if you are clear about your opinions regarding specific controversial topics. For more information, refer to Assessing Your Beliefs about Whole Health.
Ensure that they are safe. What is the worst-case scenario if they act according to their beliefs, and what are the odds that scenario will occur? If a preferred treatment or approach is unlikely to cause harm, and if they are not in urgent danger if they fail to receive conventional medical care that is indicated, is it possible to give them some leeway?
Share your beliefs and opinions. You have a right to have your beliefs known too. Respect theirs, but respect yours too. Be careful not to proselytize. Be aware of the basis for your own opinions. Do not argue, and do not give the impression of being derisive or judgmental, or you will get nowhere. Remember, they are likely seeing you because they want to know your opinion, based on your training and expertise.
Give them the facts. Part of your role is to educate, to impartially tell them what the research tells us to date, or what your experience shows has worked for others in similar situations. It can be helpful to have a list of evidence-informed books or websites to recommend for them. Make good use of the multiple online resources offered by the VA.
Examples of reliable general health websites include:
- Medline Plus.
- Centers for Disease Control.
- The National Institutes of Health website.
- Mayo Clinic Health tools.
- Cleveland Clinic.
- Family Doctor.org.
And some Integrative Medicine sites:
- University of Wisconsin Integrative Medicine.
- University of Minnesota, Taking Charge of Your Health and Well-Being.
- University of Arizona, Free Integrative Medicine Tools.
Dont be afraid to say you dont know. Do not criticize a belief simply because you do not understand it. It is okay to do your homework after the visit and get back to them. It is also okay to say that little is known about a topic, so it is hard for you to guide or advise them. Sometimes a pause before you give them your perspectives will allow you to mindfully share your own perspectives in greater detail.
Be mindfully aware. Ask what the emotional context of the visit is for you. Are you feeling angry, nervous, sardonic, skeptical, or trying to suppress laughter? Why do you feel that way? If it is uncomfortable for you to discuss their concerns, be honest with them about that.
Patient-centered care moves us out of the era where clinicians could simply tell patients what to do. And the fact of the matter is that if patients do not agree with recommendations, they will not follow the treatment plan anyway. By being aware of moments where your perspectives and your patients do not match up, and by following these simple guidelines, you may find that you not only engage the patient more fully in the Whole Health visit, but you also strengthen your therapeutic relationship. As that relationship evolves, you may find that patients are much more likely to take your recommendations into account.
“How Do You Know That? Epistemology and Health” was written by J. Adam Rindfleisch, MPhil, MD, (2014, updated 2018).