Just the Facts


Every professional school comes with its own flavor of education, its own sensibility. In law school there’s the Socratic Method; the wizened sage scanning the crowd to call on that one poor soul who didn’t spend last evening buried in the reading assignment. Business students practice how they’ll play, fraternally conferencing in rooms trimmed with oak and high-backed leather chairs.

Then, there’s medicine.

We convene, at 8 o’clock every morning, in a lecture hall, to listen to the facts. And there are facts a-plenty.

There are the thousands of details that govern the simplest movement of biochemical messengers, data that guide molecules steadfastly through an ocean of intracellular goop. Then there are exquisite intricacies of the body’s inner workings, and the millions of ways things can go horribly wrong. We even hear facts about how to determine the factuality of the facts we’ve already been presented.

Life, in case you hadn’t noticed, isn’t quite so clear. The answer isn’t just sitting there, tucked safely between other, multiple choices. The facts and the details do matter, but rarely does a situation come along that fits so neatly in the folds of what is supposed to suffice for medical knowledge.

The other day I saw a patient with a seemingly simple problem – high blood pressure, most certainly exacerbated by her obesity. She was one year younger than me. Now, the “facts” I’ve learned tell me that a woman with her BMI has a relative risk of 1.5-2.0 of developing coronary artery disease, compared to someone with a BMI of 20-25. I could tell her this. I could also tell her how her hypertension is slowly but inexorably damaging her blood vessels – hell, I could render a pretty good drawing of intimal hyalinization, replete with specific cell types and cascading second messengers.

I can tell her all this; or I can listen to the facts of her life. How she has trouble walking more than a few blocks – let alone exercising. How 4 of her 5 children have severe medical problems of their own, one so severe that he spends more time in the hospital than at home. How she has a prescription for a thyroid medication that she hasn’t filled for two months because she can’t afford it. How she doesn’t have insurance, can’t work, and lives – essentially – by the kindness of strangers.

It’s no secret why we love our facts. Illness is one big, scary, unpredictable force, with implications that shake us to the very core. A firm grounding in facts is one simple way to control a bit of that chaos, help us sift through the miasma of imprecision and unpredictability to arrive at something approaching certainty. But in medicine, as in the rest of life, data and facts just give us a stepping off point, a chance to weigh the evidence and taking our best guess at what to do next.

So what did I do with my patient? I offered her what I could – my version of the facts, as best as I could understand them. And she walked back into the facts of her life, most of which I can never even hope to understand.

Tomorrow, I’ll be right back in class, listening to the day’s designated expert drone on about the molecular mechanisms of some myasthenic meltdown. This time, though, I’m going to listen for the truth that comes, inevitably, with every thousand bits of complicated detail. Despite our best efforts, despite the hours and years spent mastering a body of fact – we cannot know everything.

And that’s a fact.

- Anthony Foianini