Doubt and the importance of waiting

There was an article in the New York Times recently about a software program developed by scientists at Harvard University and the Massachusetts Institute of Technology that grades essays instantly. How strange it must be to have a computer judge all the nuances of language involved in a work of prose. Multiple-choice questions alone can already be contentious, as anyone can attest who has waited months for the results of a 240-question board exam.

It gets even more hairy in real life. What I would give for the ability to examine a patient, submit my findings to some omniscient entity (Watson, maybe?), and get instant feedback.

Unfortunately, this is not how rheumatology works. The temporal artery biopsy does not always come back positive, and when it doesn’t, it becomes much harder to know what to do when a patient relapses once he is down to 20 mg of prednisone. And how do I justify putting a refractory dermatomyositis patient on a toxic immunosuppressant when her muscle biopsy is negative and all I have to base my decision on is a highly suggestive skin rash?

Very little of what we do as rheumatologists is evidence based. Doubt is a recurring theme in my practice. I am lucky that I practice with other physicians with whom I can bounce ideas around and that I maintain a relationship with previous mentors who are always ready with good advice. I am fortunate to be close enough to Boston that many of my scleroderma patients can get enrolled in trials. But doubt is ever-present and is very frequently the cause of not insignificant personal malaise.

Here’s what’s even more striking about the essay-grading software, and even more pertinent to our nebulous field: they’ve eliminated waiting. According to the Times article, a student can submit an essay, receive feedback right away, and resubmit the essay in an attempt to get a better grade. That is an enviable state of affairs.

There is, however, something to be said for waiting. Patience is a defining virtue in rheumatology. We wait for a patient with vague symptoms to develop more symptoms or to "declare" themselves. We wait for labs and pathology reports and imaging findings. Perhaps most importantly, we wait for either a response to treatment or for the other shoe to drop.

By promising instant feedback to students, are we not depriving them of an important life lesson? After all, we spend our lifetimes waiting. We wait to grow up, to get our driver’s licenses, to hear about school or job applications. We eagerly wait for holidays, for meals to be served, and for spring to arrive. We wait to grow older. We wait to recover from illness.

As Father James Donelan, S.J., put it, "Waiting is a mystery – a natural sacrament of life." Waiting teaches us to have patience and self-control, to innovate and be imaginative. Waiting feeds our curiosity and cultivates a sense of wonder.

There is something to be said for learning to be comfortable with disquiet. Through doubt and waiting we learn to ask questions. And in a field like ours, where our scope of knowledge is so tiny compared with what we have yet to learn, questioning is not a bad word. Vladimir Nabokov, who was also an entomologist apart from being a writer, said it best: "There is no science without fancy and no art without fact."

Dr. Chan practices rheumatology in Pawtucket, R.I. This column, "Rheum in Bloom," appears regularly in Rheumatology News.

There was an article in the New York Times recently about a software program developed by scientists at Harvard University and the Massachusetts Institute of Technology that grades essays instantly. How strange it must be to have a computer judge all the nuances of language involved in a work of prose. Multiple-choice questions alone can already be contentious, as anyone can attest who has waited months for the results of a 240-question board exam.

It gets even more hairy in real life. What I would give for the ability to examine a patient, submit my findings to some omniscient entity (Watson, maybe?), and get instant feedback.

Unfortunately, this is not how rheumatology works. The temporal artery biopsy does not always come back positive, and when it doesn’t, it becomes much harder to know what to do when a patient relapses once he is down to 20 mg of prednisone. And how do I justify putting a refractory dermatomyositis patient on a toxic immunosuppressant when her muscle biopsy is negative and all I have to base my decision on is a highly suggestive skin rash?

Very little of what we do as rheumatologists is evidence based. Doubt is a recurring theme in my practice. I am lucky that I practice with other physicians with whom I can bounce ideas around and that I maintain a relationship with previous mentors who are always ready with good advice. I am fortunate to be close enough to Boston that many of my scleroderma patients can get enrolled in trials. But doubt is ever-present and is very frequently the cause of not insignificant personal malaise.

Here’s what’s even more striking about the essay-grading software, and even more pertinent to our nebulous field: they’ve eliminated waiting. According to the Times article, a student can submit an essay, receive feedback right away, and resubmit the essay in an attempt to get a better grade. That is an enviable state of affairs.

There is, however, something to be said for waiting. Patience is a defining virtue in rheumatology. We wait for a patient with vague symptoms to develop more symptoms or to "declare" themselves. We wait for labs and pathology reports and imaging findings. Perhaps most importantly, we wait for either a response to treatment or for the other shoe to drop.

By promising instant feedback to students, are we not depriving them of an important life lesson? After all, we spend our lifetimes waiting. We wait to grow up, to get our driver’s licenses, to hear about school or job applications. We eagerly wait for holidays, for meals to be served, and for spring to arrive. We wait to grow older. We wait to recover from illness.

As Father James Donelan, S.J., put it, "Waiting is a mystery – a natural sacrament of life." Waiting teaches us to have patience and self-control, to innovate and be imaginative. Waiting feeds our curiosity and cultivates a sense of wonder.

There is something to be said for learning to be comfortable with disquiet. Through doubt and waiting we learn to ask questions. And in a field like ours, where our scope of knowledge is so tiny compared with what we have yet to learn, questioning is not a bad word. Vladimir Nabokov, who was also an entomologist apart from being a writer, said it best: "There is no science without fancy and no art without fact."

Dr. Chan practices rheumatology in Pawtucket, R.I. This column, "Rheum in Bloom," appears regularly in Rheumatology News.

There was an article in the New York Times recently about a software program developed by scientists at Harvard University and the Massachusetts Institute of Technology that grades essays instantly. How strange it must be to have a computer judge all the nuances of language involved in a work of prose. Multiple-choice questions alone can already be contentious, as anyone can attest who has waited months for the results of a 240-question board exam.

It gets even more hairy in real life. What I would give for the ability to examine a patient, submit my findings to some omniscient entity (Watson, maybe?), and get instant feedback.

Unfortunately, this is not how rheumatology works. The temporal artery biopsy does not always come back positive, and when it doesn’t, it becomes much harder to know what to do when a patient relapses once he is down to 20 mg of prednisone. And how do I justify putting a refractory dermatomyositis patient on a toxic immunosuppressant when her muscle biopsy is negative and all I have to base my decision on is a highly suggestive skin rash?

Very little of what we do as rheumatologists is evidence based. Doubt is a recurring theme in my practice. I am lucky that I practice with other physicians with whom I can bounce ideas around and that I maintain a relationship with previous mentors who are always ready with good advice. I am fortunate to be close enough to Boston that many of my scleroderma patients can get enrolled in trials. But doubt is ever-present and is very frequently the cause of not insignificant personal malaise.

Here’s what’s even more striking about the essay-grading software, and even more pertinent to our nebulous field: they’ve eliminated waiting. According to the Times article, a student can submit an essay, receive feedback right away, and resubmit the essay in an attempt to get a better grade. That is an enviable state of affairs.

There is, however, something to be said for waiting. Patience is a defining virtue in rheumatology. We wait for a patient with vague symptoms to develop more symptoms or to "declare" themselves. We wait for labs and pathology reports and imaging findings. Perhaps most importantly, we wait for either a response to treatment or for the other shoe to drop.

By promising instant feedback to students, are we not depriving them of an important life lesson? After all, we spend our lifetimes waiting. We wait to grow up, to get our driver’s licenses, to hear about school or job applications. We eagerly wait for holidays, for meals to be served, and for spring to arrive. We wait to grow older. We wait to recover from illness.

As Father James Donelan, S.J., put it, "Waiting is a mystery – a natural sacrament of life." Waiting teaches us to have patience and self-control, to innovate and be imaginative. Waiting feeds our curiosity and cultivates a sense of wonder.

There is something to be said for learning to be comfortable with disquiet. Through doubt and waiting we learn to ask questions. And in a field like ours, where our scope of knowledge is so tiny compared with what we have yet to learn, questioning is not a bad word. Vladimir Nabokov, who was also an entomologist apart from being a writer, said it best: "There is no science without fancy and no art without fact."

Dr. Chan practices rheumatology in Pawtucket, R.I. This column, "Rheum in Bloom," appears regularly in Rheumatology News.