Psychologically and experientially the passage of time is malleable. It accelerates during novelty and decelerates with redundancy. It is cyclical but also linear. Depending on perspective or motives, it can be progressive or regressive. The natural world is rooted and synchronized to the cyclical nature of days and nights and the rhythms of the seasons. Psychologically, a birthday, an anniversary, or a New Year affords opportunities for reflection, resolutions, and renewals. However, time is also linear — moving from the past to the present and into the future — elucidating direction, trends, causes, and effects.
So to begin with and in the spirit of reflection, I would like to reflect on the last year of essays. In retrospect, a general theme that emerged from these essays was decision making, the role of evidence and the types of evidence in medicine. Emergency department’s are semi – unstructured environments and understanding emergency physician decision making through the lens of known-unknowns and unknown-unknowns offers an alternative to the risk-seeking and risk-averse models that describe this behavior. Although humans differ from other animals in being able to systematize and quantify our models, emergency physicians are often “reduced” to experience, memory, pattern recognition, and direct feedback to learn and make predictions in these unstructured worlds. However, decisions made on calibrated heuristics are invaluable in a semi-controlled environment such as emergency departments where typical patients are often atypical.
The evidence based medicine movement (EBM) – derived from the larger empirical tradition of science – has taken hold in medicine and is the de facto driver of decision making. EBM is unique in that it systematically ranks evidence sources with double blinded randomized controlled trials (dbRCT) residing at the top of that hierarchy. The limitation of dbRCT is that it is often not generalizable to the large segments of the larger population. Thus, real world evidence generated from real world data has moved to the forefront of evidence generation. However, “no tool is omnicompetent” and as Alfred North Whitehead said, “the art of progress is to preserve order amid change and to preserve change amid order.” We often become anchored to dichotomies but moving beyond polarities and thinking with the framework of the tetralemma can serve to bridge the gap or provide an alternative to dichotomous thinking.
The directionality of time is often displayed in terms of progress. Progressive trends in the material improvement of human life — as measured by life expectancy, GDP, poverty — abound in our modern world of data and statistics. Nonetheless, as Stephen Hawkings wrote, “the increase of disorder or entropy with time is one example of what is called the arrow of time, something that distinguishes the past from the future, giving a direction to time.” Charnel grounds were symbols of suffering and impermanence but also a sensually dramatic characterization of the entropy that ultimately governs the universe. As we move into the new year, I want to spend time looking at the evolutionary underpinnings and energetic foundations that lead to the human diseases of modernity – Alzheimer’s, Cancer, Diabetes, and Sepsis.