As a surgeon, I have always had a difficult time acknowledging the need for help, especially in the operating room. I am not sure whether it is a personal issue, a trait of my brethren surgeons or an extension of the male desire not to ask for directions. I have less difficulty asking for help outside my area of expertise. Asking for help at work consists of asking for consultation and it drives medical costs for hospitalized patients. Understanding why we ask for help, and the networks we organize around those needs is something I have been given a lot of thought to lately.
Why ask for help? Usually because of a deficit in either my knowledge or my knowhow. Duh. Cesar Hidalgo wrote about the distinction in Why Information Grows
… knowledge involves relationships or linkages between entities. These relationships are often used to predict the outcomes of events without having to act them out. … Knowhow is different from knowledge because it involves the capacity to perform actions, which is tacit.
My need for consultation includes both knowledge and knowhow, not necessarily in equal measure. I understand many linkages outside my area of primary expertise. For instance, a failing heart puts increasing ischemic stress on the kidneys which result in fluid overload to further stress the failing heart. These linkages can involve pathophysiology, drug interactions or the current antibiotic biogram. It is the knowledge of our medical training. Book knowledge, already codified and searchable either within our minds or with the assistance of a Google. This knowledge defines our comfort zone.
Knowhow, on the other hand, implies action, categorized as relational, somatic and collective. One might think of the heart failure example when it lies on ‘the tip of your tongue,' just out of consciousness and explication as an example of relational knowhow. For whatever reason, you know the linkages but are a ‘bit rusty’ of how best to identify, triage and manage the situation. Somatic knowhow refers to actions done with our bodies; this is home to interventionalists; this is the biopsy, catheterization, surgery. Together knowledge, relational and somatic knowhow are the deficits that consultation mitigates.
I love this class quote from Donald Rumsfeld
There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don't know. But there are also unknown unknowns. There are things we don't know we don't know.
I’ve tried to map his view of knowns onto our understanding of consultation.
Well, the known knowns are easy. It is my comfort zone, the area of my credentialed expertise. I rarely formally seek help here. Most of the time when we're looking for guidance, if at all within our comfort zone, it begins with the words, “I have an interesting case….” I think we do this more to reassure ourselves that we have been thorough in our thinking or planning. As I reflect upon it, my real hesitancy to ask for help is more often, although far less frequently, in the operating room, rather than ‘floor’ care. I suppose that it negatively impacts the perception of my somatic knowhow or skillset. I feel less threatened by the gaps in my relational knowhow. For the primary care physicians and medical specialists, I suspect that it is just the reverse, deficiencies in cognition weigh more heavily upon their sense of self.
For some issues, I ask for help, in other situations, not so much. Endocrinologists are rarely consulted on the management of diabetes by any physician – after all, there’s an algorithm for that. (Sliding scale or basal-bolus). Relational knowhow may be a little more ambiguous than other knowhow or more amenable to explicit capture (order-sets) or perhaps, as I have suggested, it has an emotional component. In any case, relational knowhow explains the fuzzy border of the comfort zone, separating the most confident in their skills from the less confident or from those with greater risk aversion. That is why some physicians feel abler to provide, safely, care outside their comfort zone.
Unknown knowns, not knowing that help is available is perhaps the most difficult to address, it is the bane of the consultant who complains of being called “too late” when it suddenly dawns on you that you need help. Or it comes back to haunt you as grist for the malpractice mill. It requires reflection for the need to be evident, to become a known unknown. But for the reflective mind, it can be memorialized as experience and applied in the future. Hopefully, the unknown knowns diminish with time.
Finally, unknown unknowns are that category of patients where the conversation often begins with ‘In my experience’ and ends with ‘sh*t happens’. It may yet yield to our scientific inquiry but hasn’t at this juncture. It is the home of conjecture and the nursery of innovation.
There is a third form of knowhow, collective knowhow, which Hidalgo characterizes as
“knowledge that draws meaning from social interaction…”
It is the home of knowledge contained by a team and underlies the structure of consultative networks that individuals create. Our collective knowhow forms the basis for identifying when to seek assistance and from whom. The strength and resilience of consultative networks lie in collective knowhow. It is what separates the Sloan Kettering or Mayo Clinics from your community hospital. Understanding and facilitating how our consultative networks form is a function of hospital culture.