Shadows in my surgery and how I consult in Plato’s cave

As I sit in my consulting room the window blinds are permanently down, both maintaining privacy while blocking out any natural light from the sun. The room is lit with a low energy saving light bulb and the glow of a computer monitor. My eyes are fixed to the screen apart from when I ascend a long corridor to the waiting room and call through the next patient. My professional life is spent inside Plato’s cave.


Learning objectives

1. Read Plato’s Allegory of the Cave

2. Consider the difference between knowledge and belief

2. Think about checking your own vitamin D levels


The Allegory of the Cave is presented in The Republic by Plato. Although I encourage visitors to read a complete version, one translation is available here or a youtube animation here. Alternatively, below is a synopsis of the allegory.

Plato has us imagine human beings living inside a cave since they were children. They are chained in such a way that they cannot move and can only look towards the wall of the cave. Behind and above them is a fire. Between the fire and the people some puppets appear, therefore projecting their shadows onto the wall of the cave. These projections are the only things these people have seen and they assume them to be real. Even as they talk, the echo of their voices in the cave appear to be originating from the shadows. The prisoners devise what they believe to be clever means predicting and systematising the projections and determine them to be real whereas they are nothing but shadows of the objects behind them. What would happen if one of these people was released from their chains and free to turn around and move towards the source of the light? The light would be painful to look and the objects difficult to visualise. The unchained prisoner would want to turn back towards the wall to the comfortable shadows. However, the unchained prisoner is forcibly dragged outside the cave now suffering from the glare of the sun. They experience yet more pain but eventually their eyes adjust, finally seeing the sun. The unchained prisoner reflects on how naive his fellow prisoners were believing the shadows on the wall were the true nature of things and pities them. They go back into the cave to tell the others of life outside the cave, however the unchained prisoners eyes are no longer adapted for the dark conditions and struggles to see. The chained prisoners laugh at the returning traveller and express no desire to be free. Indeed, they would violently react against anyone who tried to release them from their chains.

All very well, but how does this relate to medicine? As clinicians we listen to the description of symptoms and try to elicit signs from patients to understand their disease process and reach a diagnosis. These verbal reports and signs could be regarded as echos and shadows of the underlying illness. An irregular pulse, jaundice, clubbing, all signs which lead the clinician down a path of diagnosis.


Questions

How useful do you find symptoms and signs in reaching a diagnosis?

How do investigations such as blood tests or imaging alter your diagnostic perception of the patient?

Have you come across instances where you may have been led astray by relying on results too much?


Imagine a situation where you have just examined someone. On auscultation, the chest was clear. The patient seeks a second opinion and is immediately examined by another doctor who diagnoses a chest infection.


Questions

Is one doctor right and the other wrong?

Can both doctors be right and wrong?


You both agree that a blood test would be interesting if not helpful. Two samples are taken simultaneously, one on each arm and sent to an identical laboratory. The results come back and are not only different from each other, but are also ambiguous due to other patient comorbidities. To clarify the situation you decide to arrange a chest radiograph. However, two reporting radiologists disagree as to whether some of the markings on the film are indicative of an infection or just the result of an artefact. One of the doctors involved thinks about further imaging but an another is concerned radiation exposure although no one is certain of the risk in this individual patient. Someone suggests empirical antibiotic treatment but a colleague warns about potential side effects and antibiotic resistance.

There are plenty of Platonic shadows (if not actual radiological ones) in the scenario presented above and as doctors we learn to live with uncertainty but continue to try and find the truth. Continued learning, gaining experience and research help us make wiser but not necessarily perfect decisions. Living and working with uncertainty is why some say that medicine is both a science and an art.


Questions

How can you be certain that medical information is an accurate representation of reality?

Can you trust your own senses and experiences?


Socrates compares the unchained prisoner in Plato’s cave to a philosopher. However, we could also imagine the free prisoner as a lay person transitioning to a physician. Learning anatomy, biochemistry, physiology (and the rest) through to evidence-based medicine with clinical experience may give a clearer picture of the truth of bodily human function and disease.

However, a stethoscope, a radiograph, a computer screen displaying blood results are all shadows of health (or lack of it). We use these to reach a belief about a situation and create systems of diagnoses based on our own and collective experiences. However, this second, third even fourth hand information may be a distortion of the reality of the disease process and the illness affecting the patient.

I will certainly be returning to Plato again but I hope this introduction lays some of the foundations for future discussion. In the meantime I’m feeling rather tired and think it’s time to take my daily dose of vitamin D or sunshine.


Summary

Although (sadly) doctors aren’t often exposed to the works of Plato while training, they can still make excellent philosophers. With all the uncertainty they face, how could they not?


Further resources

Practicing medicine in Plato’s Cave
https://www.ncbi.nlm.nih.gov/pubmed/16750954

On departing Plato’s Cave: the philosophical privilege of medical education
http://msja.anu.edu.au/archive/issue/02/the-philosophical-privilege-of-medical-education.php

From the outside of plato’s cave
https://www.ncbi.nlm.nih.gov/pubmed/14681567

 

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