Death through Misunderstanding Practice in the COVID-19 Crisis
As an engineer and engineering educator, I have devoted decades of considerable reflection and study to better understand the distinction between engineering science and practice, but in recent days it has become clear that the media, certain politicians, certain medical professionals, and much of the public at large is profoundly confused about the difference between science & practice, more generally. Normally, this confusion is merely amusing or annoying to those of us who make our livings riding the edge of the science-practice distinction, but in the era of COVID-19, the misunderstanding is, in my view, leading to bad political decision making which is hampering effective medical practice thereby possibly causing unnecessary illness & death from the disease.
Distinguishing Theory & Practice: Yogi’s Version
Yankees catcher and manager, Yogi Berra, made the distinction between theory and practice quite well in one of his Yogisms:
In theory, there is no difference between theory and practice. In practice there is.
Like many Yogisms, this one creates an irreconcilable puzzle that invites a deeper dive to fully fathom the phrase. Fortunately, in 1983, Donald Schoen at MIT, published an important text The Reflective Practitioner, that offers some help in this regard.
Distinguishing Theory & Practice: Schoen’s Version
In The Reflective Practitioner, Schoen says that there are 2 approaches to thinking about practice.
- Technical rationality
- Reflection-in-action
The first of these notions of practice, technical rationality, is the one taught in professional schools these days in which theory is taught first and and then later (sometimes, much, much later) applied in practice. The idea is simple. Practice is merely the application of well known and accepted theory. As I have written in A Whole New Engineer and elsewhere, this idea is OK as a theory of practice when we confront a known problem, because existing theoretical knowledge gives us particular guidance; however, technical rationality is a really lousy theory of practice because it offers almost no guidance when practitioners face an unknown or unsolved problem.
In such circumstances, Schoen observes practitioners in action (architects, therapists, and even scientists), and notices something important. When faced with unknown or unsolved problems practitioners engage in reflection-in-action calling on their theoretical knowledge as well as their practical experience to try to put together possible ways to deal with the unknown situation.
He calls this process reflection-in-action and calls out its conversational nature. The importance of conversation to this kind of creative problem solving is especially important. In particular, it is important to notice, listen and question to deepen one’s understanding of the unknown problem and possible solutions.
Noticing, Listening & Questioning (NLQ) Stories in Practice
A key element of reflection-in-action is to notice, listen, and question (NLQ) to your client/patient’s stories. Media pundits are quick to dismiss anecdotal evidence as unscientific, but taking a good case history is central to great practice. Great practitioners notice their individual patients/clients, their language, their symptoms, ask probing questions, listen, notice and question some more.
Central to this is the notion that practice is about particular instances, the individual patient or client. In engineering it is about solving the problem or creating a great design. In medicine, practice is about treating the client as an individual according to the symptoms they face. In medicine, science is about establishing a general case or theory that can be applied.
HCQ Cocktail as a Case Study in Proper Science & Practice
I am not a medical practitioner, but as a layman, it appears to me that the results in France, South Korea, China and the US suggestively pointing to hydoxychloroquine (and chloroquine) and azithromycin, the so-called HCQ cocktail, as being helpful in certain cases of COVID-19 is an important case to understand from the practice-science perspective. There are three perspectives to consider:
- Scientific perspective. As a matter of science, Dr. Faucci and others from the CDC and FDA want more scientific evidence before recommending the cocktail widely. Their duties are to consider the general case from a solid footing as they are doing.
- Medical practice perspective. Individual medical practitioners, having heard of the efficacy of the drug cocktail in particular cases are prescribing the cocktail to particular patients. There are anecdotes of the cocktail working and not working, both. This is as it should be. Individual doctors should be free to use their medical judgment to help individual patients to the best of their ability with the available knowledge and knowhow of the times.
- Political practice perspective. President Trump and Governor Cuomo and other leaders are urging wider spread use of the HCQ cocktail in practice now to mitigate death and to permit partial reopening of the economy. As political practitioners, they have to use current evidence (both scientific and anecdotal) to try to get the best result for the polity as soon as possible.
Note, that the Trump-Cuomo practice is in alignment with both medical science and medical practice. Do more science and establish HCQ in general terms as time permits, but in the meanwhile encourage best emerging medical practice for best political outcome.
HCQ Cocktail as Case Study of Political Malpractice
Unfortunately, Governors Witmer (of Michigan, my state) and Sisolak (Nevada) have issued executive orders forbidding individual medical practitioners from prescribing the HCQ cocktail for their patients. They do this on “science” grounds, but their actions show that they misunderstand science and practice both. Prohibiting old, well established drugs from being used off-label in an emergency on scientific grounds is itself unscientific. In essence, in the face of unknown harm of COVID-19 to particular patients, both governors are prohibiting the use of old, safe drugs with known side effects from being used by experienced practitioners to help their patients in need. This makes no sense scientifically or as a matter of practice.
To better understand the malpractice here, imagine that S. Korean researchers found that a combination of rice pudding and bananas was effective in treating COVID-19. If Governors Whitmer and Sisolak were logically consistent with their HCQ prohibition, they would prohibit Michiganders and Nevadans from eating rice pudding and bananas because of the lack of scientific evidence for their curative effect.
Moreover, given that practice is fundamentally conversational, prohibitions by central authority essentially shut down little bets and conversation between informed practitioners that can benefit their patients. In this way Governors Whitmer and Sisolak commit a form of egregious political malpractice in their actions. I urge them both to rescind their orders and let medical practitioners practice the medicine for their individual clients as best they can in difficult circumstances
Understand Science-Practice Distinction Now
Elsewhere, I have advocated for a better understanding of the science-practice distinction in the education of all professionals. In the current environment, it is important to keep this distinction in mind and avoid needless loss of life through the prohibition of possibly lifesaving treatments lawfully available to medical practitioners.
Moreover, media pundits and politicians would do well to stop worshipping at the false altar of science and recognize the science-practice distinction as important. We need science and practice, both, right now as we face the challenges of COVID-19 in medicine and as a polity.
“It’s time for university leaders to get serious about changing the way they teach students, says higher education thought leader Dave Goldberg, in this episode. Dave says it’s time to change higher education from the inside out. He says that, in preparing students for their careers, educators should help students shift their focus away from obedience to authority, and, instead, guide them towards the development of human values. The change in the teaching of students should resemble the way that the job of leadership is changing…”