Sunday, March 31, 2013

Questioning, Listening and True Learning

“If men learn this, it will implant forgetfulness in their souls; they will cease to exercise memory because they rely on that which is written, calling things to remembrance no longer from within themselves, but by means of external marks. What you have discovered is a recipe not for memory, but for reminder. And it is no true wisdom that you offer your disciples, but only its semblance, for by telling them of many things without teaching them you will make them seem to know much, while for the most part they know nothing, and as men filled, not with wisdom, but with the conceit of wisdom, they will be a burden to their fellows.”
Plato, Phaedrus

This week, I sat down with my family for the traditional Passover Seder with the reading of the Haggadah and the ongoing questions and discussions that are the central part of the evening.  The feast of freedom, as one Haggadah calls it, is based on questions as being free means being able to question everything without fear.  The written word of the prayers and the story of the exodus from Egypt, while important, are not as important as that interactive dialogue that ensues and that is expected and even mandated by the holiday.  Each section is designed to elicit conversations, questions, and thoughts that lead to the participants gaining intrinsic knowledge.  This is in keeping with Plato’s contention that merely reading is not a way to impart knowledge.  True knowledge must come through dialogue and creating an internal understanding of the topic at hand.  I have found this to be particularly true in health care and in endeavors to help people obtain quality care from our health care system. 
The first step in internal understanding as Plato understood is to ask a question and then listen to and hear the answer.  Each year at our family Seder, it starts with the four questions asked by the youngest in the home.  My grandchildren, age 7 and 5, are asked (and were asked as soon as they could talk) to form their own questions at that section and throughout the Seder in addition to the standard four questions.  Everyone at the table is encouraged to ask questions.  The questions themselves are always more important than the answers as the questions allow a discussion to start: a back and forth of the type that is more likely to produce learning and understanding.  Isidor Rabi, who won the Nobel Prize in physics, was once asked why he became a scientist.  He answered, “My mother made me a scientist without ever intending it.  Every other Jewish mother in Brooklyn would ask her child after school: ‘Did you learn anything today?’  But not my mother.  She always asked me a different question.  ‘Izzy’, she would say, ‘Did you ask a good question today?’  That difference – asking good questions – made me become a scientist.”
Plato, in writing his dialogues, often presented Socrates as a questioner.  Our understanding of Socrates is through these dialogues written by Plato.  Plato and Socrates believed that just reading something, rather than discussing something, could not lead to true learning and could instead lead to an intellectual laziness which would produce people who “for the most part they know nothing, and as men filled, not with wisdom, but with the conceit of wisdom”.  Plato tried to recreate that give and take by writing as dialogues.  Implicit then in this approach to questions leading to dialogue is the assumption that after the question is asked, there must be true hearing of the answers, if only to be able to formulate the next question! 

That resultant listening is really an exercise in interpretation and then in testing that interpretation with yet another question.  Thus the iterative nature of a good clinical interview is really no different than a Socratic dialogue or a discussion elicited by a question at a Seder table.  Plato and Socrates believed that only in such a manner could learning occur and Professor Rabi believed that only in that matter could unique, creative scientific inquiry truly occur.  In medicine and law, that tradition of asking question and then eliciting discussion, dialogue, and research, is at the heart of education and training.  It is believed that intrinsic learning occurs in the iterative nature of the teacher and the student having such a “dialogue” on the topic and situation at hand. 

The goals of using such a system of questions followed by dialogue in health care are to create a better understanding between a care giver, a care supporter, the person in need and often the family in need.  That understanding then leads to better, more personalized care for that unique individual.  It allows for intrinsic learning for the patient who needs to do certain things, whether it is to take certain medications, stay on a diet, or follow through on therapy.
Currently, there are those who believe that technology can make this dialogue unnecessary.  A professional forming a relationship with a person in need is believed to be too costly and even wasteful when powerful big data, interactive Internet tools and apps that are with us wherever we go can be used instead.  Engaging in dialogue is believed to be too expensive and too difficult.  Yet we should share the same fears in this era as Socrates and Plato did in their era: the fear that we will not achieve intrinsic learning, either on the part of the care giver or of the patient by the mere reading of an Internet page or the use of an app.  We still need those dialogues that lead to true relationships in order to create the intrinsic understanding that leads to action on the part of people who are patients living their lives with their families, their work, and their friends.  The technology is welcome but only if used to foster the dialogues and to assist in the development of the relationships that are at the heart of good practice and good care. 

Thus asking the right questions, truly hearing the answers and using that as a starting point for dialogue are crucial steps in creating good quality care.  That may not win any Nobel prizes or lead to the entirety of Western philosophical thought; however for me, as a dedicated health professional, it is an art that we should continue to foster and not allow to be lost in the excitement over technological solutions.