Clinical Skills Are Not Necessarily Impaired, but Rather May Be Improved by Ageing

2017;65:288-292 REVIEW Clinical skills are not necessarily impaired, but rather may be improved by ageing V. Bonavita University Federico II, Naples – Professor Emeritus of Neurology and President of Istituto di Diagnosi e Cura Hermitage Capodimonte, Naples, Italy Introduction. A clinician is an observer of nature, of a biased nature, an observer that cannot use Aristotle’s induction method, even as reviewed by Bertrand Russell, but rather the deduction method, as outlined by Albert Einstein and developed philosophically by Karl Popper, Pierre Duhem and by Augusto Murri –Popper’s ancient forerunner. One might also mention Antonio Cardarelli – a very intuitive clinician –a follower of Bertrand Russell and of the induction method. The ability to advance hypotheses may even be strengthened in time and as a practical experience enhanced upon ageing. Successful old age and teaching. A clinician experiencing a successful old age is a wealth that should not be wasted in practice nor, perhaps, in teaching. The advantage of a well-preserved old man, also vs a clinician still far from his sixties, is then in the number of stories and, with respect to clinical semeiotics, in the skilfulness of the examination derived from long-term practice. The problem of the old man, besides losing his neurons, is the capacity of the cognitive reserve based on what Ernesto Lugaro – professor of nervous and mental disease clinics in Turin in the past century – called “neurotropism of the functioning neurons”, i.e. the tendency of neurons to form synapses. The challenge of learning the Information Technology language, grows with ageing and lastly, an old individual enjoys the well-known pleasure of paper communication. Old clinicians and the general intelligence. A well-aged old clinician retains all the general intelligence developed in his or her youth, and continues to make the best use of it to set and solve problems. Teaching clinics: true clinics, if not experienced as a practitioner, cannot be taught, nor preserved as a perennial intellectual asset of a well-aged old person (or well-made old person) echoing La tête bien faite by Edgar Morin. Making a diagnosis. The problem here is still the warning of the clinician, of each one of us, that making a diagnosis means knowing a fragment of the real world of which we are part, and that knowing is only possible through a method. A well-made old person knows all this and must teach it through practice, which is also made of tiny observations that are not mentioned in treatises, but should be handed down verbally before they are lost. As Leonardo Bianchi noted in his last academic lecture on old age “we were and are excited about youth, it stimulated often my thoughts, it brightened up my existence year after year with spring fruits”. Key words: Induction method, Deduction method, Successful ageing, Teaching, True clinics, Making a diagnosis, Skilfulness INTRODUCTION quoting Albert Einstein (1879-1955): “without a theory it would be impossible to extract significant informa- You should hardly be surprised that a clinician, a clinical tion from the background noise of the countless data neurologist like myself, who is supposed to explain how recorded in nature”. This statement conveys two main the diagnostic and treatment skills do not loose mo- features of a clinician’s work – albeit without mentioning mentum throughout a lifetime, may open his remarks them: 1. the need to have a theory, i.e. a prior knowledge ❚ Received: December 29, 2016 - Accepted: November 13, 2017 ❚ Correspondence: V. Bonavita, University Federico II, Naples – Professor Emeritus of Neurology and President of Istituto di Diagnosi e Cura Hermitage Capodimonte, 80131 Naples, Italy - E-mail: [email protected] Successful ageing 289 every time a problem is encountered (the problem will figures that had a strong influence on the history of clin- be identified with the patient, since no patient can be ical medicine. Among them Antonio Cardarelli (1831- seen other than as a problem); 2. the need to draw 1927), who was a professor of internal medicine in Na- significant data from the background noise of the story. ples; while he refrained – in his lectures – from issuing A clinician is an observer of nature, of a biased nature, any provisions on the method he implicitly used; he was an observer that cannot use Aristotle’s induction meth- indeed a follower, as we would say today, of Bertrand od, even if reviewed by Bertrand Russell (1872-1970), Russell and of the induction method. but rather the deduction method, which is inferred in the above quote of Albert Einstein and was developed philosophically by Karl Popper (1902-1994) and Pierre WHAT IS INTUITION? Duhem (1861-1916). You see, clinicians are often seen as the Cyrenians of science, a judgement that can only What is a clinician’s intuition or, more generally, intuition? be shared if referred to non-clinical clinicians, i.e. the And how does it develop in time? It turns out from read- prescribers of instrumental examinations with which ing Plotinus (203/4-270) or Thomas Aquinas (1225- they do not aim at refuting one or more hypotheses 1274) that “intuition is the immediate and total act by originating which God acknowledges the world”: for me, as a clini- from the story. I mentioned Karl Popper, but the phi- cian, it is an abstract definition and, as such, irrelevant. losophy of knowledge by conjectures and refutations At a lower level, I will quote Pietro Greco, director of the has an ancient forerunner – Augusto Murri (1842-1932), Master in Science Communication at Scuola Internazi- who was a professor of internal medicine in Bologna onale di Studi Avanzati in Trieste: “today we can define for many years. I would like to report an abstract from intuition as a creative act… that each of us performs one of his lectures, held in 1906 1, which explains the when grasping some logical and/or scientific truth with- clinician’s work: “before we can start speaking about out passing through its formal demonstration”. But this today’s case, let me explain my thought. Today we is the point: the formal demonstration. I think that what are not facing a patient, but rather a dead body; what we call intuition is different in one respect from the rules would prevent us from opening it and making a few of classical rationality that provide for any logical and comments following necropsy? Nothing at all, but this scientific truth to pass through a formal, methodolog- is not clinics. Nor does it look like clinics to introduce ically codified demonstration: such difference is in the a patient, state his or her condition, and highlight the speed with which the mental action is performed by the symptoms. True clinics consists in training the mind to clinician. If this is the case and si parva licet comparare explore the pathways that lead to judge the disease. magnis, a clinician, whether young or old, cannot move I therefore announce that, once we have opened the away from Galileo (1564-1642) and then from Karl Pop- body on which we are going to focus today, everything per and put the hypothesis or, according to Galileo, the may look plain: the pathologist may not find anything assumption at the basis of his work. to learn. But things are different for us: now we have to predict whether this is going to be the case. If you only have to see, you may think this is one of the most THE ABILITY TO FORM HYPOTHESES obvious facts, but things are much different for those AND A SUCCESSFUL OLD AGE that need to foresee”. As you may easily understand, foreseeing means act- But does the ability to form hypotheses decline even ing according to conjectures and refuting them. This in a successful old age, or does it remain unaffected is what Murri referred to as the “elimination method”, or may even be strengthened in time and as practical which was a bright preview of Karl Popper and his phi- experience is enhanced upon ageing? As mentioned, losophy of knowledge. hypotheses originate from the story, from which the Please keep in mind this methodological introduction, background noise should be removed to grasp the the knowledge and practical application of which can meanings, i.e. the hypotheses that need to be refuted. be expanded in time and never decline, provided that Claude Bernard (1813-1878), a French physiologist, old age is a successful old age, the old age to which defined the hypothesis as “the advanced interpretation Stefano Cappa will refer in his lecture, linking cognitive of natural phenomena”, quoting John Locke (1632- reserve with a successful old age. 1704), who defined the hypothesis as the “assumed Before focusing on the specific theme I first referred to, cause of an observed phenomenon”. As you can see, there is a commonplace you may have often heard, on what is new is always partly old. which I wish to dwell for a moment. People say, “he was I think that, at this point of the lecture you have been lis- a very intuitive clinician” when referring, in particular, to tening to, an answer can be given to certain questions 290 V. Bonavita on a clinician’s maturation throughout his lifetime: 1. will merge into what Zulch (1910-1988) referred to in Who is going to be richer in terms of prior knowledge, 1969 as a “peculiar mixture of doctoring and a very high not just of the knowledge acquired in time from a grow- intellectual demand”. There is, however, a more recent ing number of readings, but also of the knowledge that issue concerning ageing individuals, namely information true clinicians can only acquire on the field – a young tecnology communication (IT).

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