Abstract
We look at the world through the lenses of our mental models. Changing our mental models refracts what we see. Even when we reflect, those reflections are refracted by whatever lenses we are wearing. Learning about complexity has altered my views of the world, but this has been in the service of something – the pursuit of excellence as a physician and teacher primarily and to a lesser, but not inconsiderable extent as an administrator and researcher. For a physician, it is the patient’s journey that is most important. However, as a physician you have the privilege of being a guide. What makes the best guide? It is not the technical skills that enable one to safely traverse the terrain, though these are important. It is not the ability to interpret a detailed typographical map of a small piece of the territory. Rather, it is the ability to see the big picture and how things connect with each other, to appreciate the complex system that is the life of the patient and his physician. Coming to appreciate complex systems was also a process of becoming a systems thinker and an intuitive one at the same time.
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Notes
- 1.
In preparation for freshman year at Columbia College, we were told to read the book “Excellence” by John W. Gardner. I don’t remember what my impression was at that time, but the idea of excellence has remained with me. I suspect it was there well before that and I was reminded of that by an article that had recently appeared in the journal of my professional society – The Endocrine Society. Howard Baum wrote that “clinical endocrinology is a field driven largely by numerical parameters. To achieve outstanding patient care, however, the clinical endocrinologist must use a range of skills that can collectively be called “clinical excellence.” Although there is extensive published guidance regarding appropriate medical management and outcomes for endocrine patients, there has been no consensus definition of excellence in the field nor any recommendation as to how excellence can be achieved” [2].
- 2.
The Chair of the Dept. was Dr. Adel Mahmoud. He was a remarkable character – very well-known but also very down to earth. When I came to CWRU, I was at the VA where faculty were considered to be second class citizens. Faculty at the University Hospital either cared about or even respected us. When I gave a talk at Endocrine Grand Rounds, no one even asked me a question. It was as if I was a pariah. A few people were different. One of them was Dr. Mahmoud who somehow heard about me and asked me to join ward rounds with him to discuss one of the team’s patients. This was long before he became Chair. Later, after becoming Chair I met with him. He told me that if I wanted to be a scientist, I should concentrate on that and if I wanted to be a clinician, I should concentrate on that, but trying to be 50–50 wouldn’t work. “Dave, you have to get off the fence.” I never did. That is an occupational hazard of foxes. I am sorry to say, that Adel recently passed away. https://www.nytimes.com/2018/06/19/obituaries/dr-adel-mahmoud-76-dies-credited-with-major-vaccines.html. 10 Aug 2018
- 3.
The astute or at least those with good eyesight will detect that the ARON letters in squadron are in a larger font. I do have an ego after all.
- 4.
Erasmus does, following the literal lead of Archilochus’s minimality, depict the styles of the fox and hedgehog as simply different, with each strategy effective in its own way, and expressing one end of a full continuum. But Erasmus clearly favors the hedgehog in one crucial sense: foxes generally do very well indeed, but when the chips go down in extremis, look inside yourself, and follow the singular way that emerges from the heart and soul of your ineluctable being and construction, whatever the natural limits – for nothing beats an unswerving moral compass in moments of greatest peril. Erasmus, after praising the many wiles of the fox (as quoted above), then adds et tamen haud raro capitur – “yet, nonetheless, it is captured not rarely.” The hedgehog, on the other hand, almost always emerges unscathed, a bit stressed and put-upon, perhaps, but ultimately safe nonetheless. And thus
intellectuals of all stripes and tendencies must maintain this central integrity of no compromise to fashion or (far worse) to the blandishments of evil in temporary power. We have always been, and will always be, a minority. But if we roll with the punches, maintain the guts of our inner integrity, and keep our prickles high, we can’t lose – for the pen, abetted by some modern modes of dispersal, really is mightier. Finally, I don’t mean to despise or dishonor the fox, and neither does Erasmus, despite his clear zinger, quoted just above, against this ultimate symbol of wiliness. For Erasmus ends his long and scholarly commentary with two stories about dialogues between the fox and another brother carnivore. The first tale of the fox and cat simply extends Erasmus’s earlier point about the hedgehog’s edge in episodes of greatest pith and moment. The two animals meet and begin to argue about better ways to elude packs of hunting dogs. The fox brags about his enormous bag of tricks, while the cat describes his single effective way. Then, right in the midst of this abstract discussion, the two creatures must face an unexpected and ultimately practical test: “Suddenly, amidst the dispute, they hear the voices of the dog pack. The cat immediately leaps up into the highest tree, but the fox, meanwhile, is surrounded and captured by the crowd of dogs.” Praestabilius esse nonnunquam unicum habere consilium (perhaps it is better to have one way of wisdom), Erasmus adds, id sit verum et efficax (provided that it be true and effective). But the second tale of the fox and panther saves our maligned character and shows the inner beauty of his flexibility, as illustrated by his avoidance of mere gaudy show for true dexterity of mind. Erasmus writes: Gould p. 7 Cum aliquando pardus vulpem pre se contemneret, quod ipse pellem haberet omnigenus colorum maculis variegatem, respondit vulpes, sibi decoris in animo esse, quod ille esset in cute. “When the panther disparages the fox by comparison to himself, because his [the panther’s] skin is so beautifully variegated with so many colored spots of all kinds, the fox responds that it is better to be so decorated in the mind than upon the skin” Gould p. 8.
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Aron, D.C. (2020). Refraction. In: Complex Systems in Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-24593-1_19
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