American College of Physicians: Internal Medicine — Doctors for Adults ®


Information and education--filling in the blanks

From the June 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Frank Davidoff, MD, FACP

The lab calls you with the latest results on your patient, Ms. Garfield, a woman in her 60s with Class IV congestive heart failure who is on digoxin, furosemide and an ACE inhibitor. Her K+ is 6.2.

What's just happened here? You might, casually, describe this transaction by saying you've learned that Ms. Garfield's K+ is elevated. But have you really been educated, in some meaningful sense of the word, or were you given a piece of information? Suppose, now, you sit down to read the latest issue of your favorite medical journal. Or attend grand rounds. Are these education or information? Are there really differences between the two? Many signs point to "yes": the fact that the language itself contains two separate and specific terms for the two concepts; the assertion of Stephen Lock, former editor of the British Medical Journal, that medical journals should both "inform and instruct" (1); and ACP's stated mission of being "the principal education and information resource for internists."

A pragmatic view of this fundamental but complex problem is to think of information as data that fill in the blanks in existing mental templates. Looked at this way, a piece of information by itself carries little meaning; rather, it acquires meaning largely from the template into which it fits. Yet information thus narrowly defined carries no less weight for all that. The information content of the word "yes," by itself, is trivial, but its impact is enormous when it fits into slots created by templates such as: "Will you marry me?" or "Do I have cancer?"

Education, by contrast, then becomes the process that creates the templates. These range from simple rule-based constructs like "If the serum potassium is elevated, stop the ACE inhibitor, increase the diuretic and recheck the potassium level," to more sophisticated models, such as the pathophysiology of congestive heart failure and the clinical pharmacology of digitalis, diuretics and ACE inhibitors, all the way to elaborate mental models at the cellular and molecular level.

The world presses in on us with enormous amounts of information. The challenge, therefore, is not how to get information but how to filter it, fit it into the right slots and keep it where it belongs. We know how information works; the difficult question is "How does education work?" How, in effect, do the templates get constructed? One view is that people acquire many of their working mental models--of the nature of things, of causality, of consequences--"naturally," and almost automatically, early in life, and mostly through experiences outside formal schooling. Moreover, while these early models are somewhat primitive or simplistic, they appear to work reasonably well for most people in dealing with most everyday problems and situations. For this reason, among others, these models are deeply rooted and extremely resistant to change (2).

In this view, most formal education appears intended to develop rote, ritualistic or conventional performances. Teachers dispense, and students acquire, thousands of chunks of information, through memorization, teaching to the test and building fragile "pseudo-templates," mental constructs that serve their purpose well enough as long as learners are working in the right context: a classroom, a homework assignment, a test.

However, such information masquerading as education is also prone to rapid disuse atrophy. More importantly, it does learners little good when they are confronted by new situations--the kind that require a deeper understanding, more flexibility and the ability to apply knowledge quickly, appropriately and gracefully to unfamiliar problems--what has been called genuine, disciplinary or expert level understanding. While there are exceptions, the evidence strongly indicates that this bleak description applies throughout the formal education system, from the earliest years through college (and on into at least the first year or two of traditional medical school teaching), from the most resource-poor school systems to the best-endowed, with bright as well as ordinary students, and from the distant past right up to the present day (3).

The role of biology

Student resistance to acquiring elaborate, more sophisticated mental models certainly contributes to the picture. But it is becoming increasingly clear that students don't resist genuine learning simply because they are intimidated, confused or pigheaded. First, resistance appears to be partly biological in origin. Thus, the brain is called on to make refined discriminations with a sensory and processing apparatus that is, at bottom, grainy and coarse; it accomplishes this in many instances by using "hard-wired" search and processing mechanisms. The result is that "we are constantly deceived about the nature of the outside world because we interpret it in terms of the built-in ... mechanism[s]" (4). The ability of these mechanisms to complete incomplete or ill-formed images and thoughts in stereotypical, biased ways is really quite dramatic (5,6).

Second, students misapply their deeply held but simplistic models in specific ways, depending on the nature of the subject (2,6). This suggests that resistance is due as much to selective dissonance between new mental models and specific familiar beliefs as it is to a more generalized "turning off." Thus, errors in science are due most frequently to the use of misconceptions; in mathematics, to rigid application of rules or algorithms; and in the arts and humanities, to stereotyping and oversimplification (2).

While the demonstration of these recurring error patterns is in some ways discouraging, recognizing them opens important alternative approaches to more effective teaching and learning, in the spirit of self-improvement, or kaizen, where "every defect is a treasure." Moreover, other recent investigations of the structure of knowledge--the character of descriptions (7) and of consciousness itself (8)--as abstruse as they seem at first, now provide important clues to ways in which mental models are built and changed, and how "genuine" education works.

The central concept here is the nature of explanations, that is, accounting for the behavior of one thing in terms of others. At their most basic, explanations in science are usually, but not always, reductionistic--they link more complex things to others that are regarded as less complex or that occupy lower levels on a hierarchy of complete descriptions, for example, biochemical explanations of disease (7).

But while many important and complex properties of higher-level entities can be rigorously understood (explained), in the literal sense, by a straightforward combination of lower-level attributes (for example, water is made up of hydrogen and oxygen atoms), it is equally important to recognize that other properties cannot. Or, stated the other way around, a theory that is sufficient for complete description at one level of organization is not, and need not be, capable of predicting properties that emerge at the next higher level (for example, excited states of electrons; chronic fatigue; societal violence). This concept of so-called "emergent properties" immediately makes the construction of mental models more complicated, but also much more interesting (7).

Other important asymmetrical explanatory relationships also emerge from this hierarchy of descriptions. Thus, while some higher-level entities (mice) can be partly understood (explained) by reference to the properties of molecules and atoms, it doesn't always work the other way around--that is, it isn't possible literally to understand molecules in terms of mice.

In other hierarchies it is only possible to understand a lower-level thing (say, clockwork) in terms of a higher-level entity (human beings, with their concepts of time and of mechanical engineering), while the converse is not true--a higher level (human beings) can't be understood in terms of a lower level (clockwork), except in a metaphorical sense.

Familiarity breeds understanding

For all its explanatory power, it is doubtful whether the descriptive hierarchy of the real world, with its emergent properties, its asymmetrical links and the vast amount of information still lacking from it, by itself can ever be the sole basis for creating adequate mental models or deep understanding; it is simply too complex, too abstract. It is here that a different species of explanatory linkage, that is, metaphor, becomes an important tool in understanding, particularly at the highest levels of the descriptive hierarchy. In fact, the psychologist Julian Jaynes goes so far as to state that "Understanding a thing is to arrive at a metaphor for that thing by substituting something more familiar to us. And the feeling of familiarity is the feeling of understanding" (8). It is certainly true, in medicine and elsewhere, that the meaning of a complex phenomenon often remains opaque until someone says "Think of it this way. It's like. ..." At an important level, the experience of illness itself can probably only be understood as metaphor (9). And, at the extreme, understanding in poetry works largely through metaphor: "The moon was a ghostly galleon, tossed upon cloudy seas. ..."

The practice of medicine clearly requires both information and education, however we define them. According to our pragmatic definitions, most medical discourse as we know it today, including medical education and medical journalism, is made up of a complex blend of information and education, which is probably inevitable and not necessarily a bad thing. At the same time, a clearer understanding of the difference between the two makes it clear just how much more there is to "genuine" education than simply filling in the blanks.

Frank Davidoff is Editor of Annals of Internal Medicine.


1. Lock S. "A Difficult Balance. Editorial Peer Review in Medicine." London: Nuffield Provincial Hospitals Trust, 1985.
2. Gardner H. "The Unschooled Mind. How Children Think and How Schools Should Teach." New York: Basic Books, 1991.
3. Koman K. Newton, one-on-one. A new way of teaching physics. Harvard Magazine. 1995; 97:18-9.
4. Bronowski J. "The Origins of Knowledge and Imagination." New Haven: Yale University Press, 1978.
5. Edwards B. "Drawing on the Right Side of the Brain." New York: St. Martin, 1988.
6. Kahneman D, Slovic P, Tversky A, eds. "Judgment Under Uncertainty: Heuristics and Biases." New York: Cambridge University Press, 1982.
7. Blois MS. "Information and Medicine. The Nature of Medical Descriptions." Los Angeles: University of California Press, 1984, p. 56.
8. Jaynes J. "The Origin of Consciousness in the Breakdown of the Bicameral Mind." Boston: Houghton Mifflin Co., 1990.
9. Sontag S. "Illness as Metaphor." New York: Farrar, Straus and Giroux, 1978.

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