The philosophy of ‘unity of knowledge and action’ in interventional neuroradiology teaching

Abstract

Despite the continuing emphasis on the importance of clinical skills, these skills do not appear to be improving and may actually be declining. The ‘unity of knowledge and action’ is a medicine directed precisely at this disease. The ‘unity of knowledge and action’ helps to learn from failure and successes, learn from mistakes of predecessors and institute a behaviour that prevents repetition of these mistakes.

‘Where does the knowledge derive from?’ ‘How is the knowledge right?’ These problems are not resolved, other words are empty. In a review, students in half of US medical schools are not attaining the medical school objectives project minimum ability to perform routine procedural skills.¹ Another study found that despite the continuing emphasis on the importance of clinical skills, these skills do not appear to be improving and may actually be declining.² In fact, both reports suggested that the training and evaluation of clinical skills should be re-emphasised. How to ensure that a clinician achieves consistent, predictable and reliable results with successive treatments and patients is paramount. We were pondering these problems for quite some time for an appropriate topic for interventional neuroradiology (INR) training. It is a genuine philosophical concept and not an analytical one. It should be capable of providing philosophical guidelines that may actually be applicable to life in general and to INR practices in particular; and, most importantly, it should have the ability to reach out to the most junior residents. The key is ‘unity of knowledge and action’.

Philosophy of ‘unity of knowledge and action’

The concept of the ‘unity of knowledge and action (zhi xíng hé yi)’ was described by Wang Yangming* during the Ming dynasty as a route to knowledge.³ Knowledge is supposed to provide that kind of certainty for action. Wang’s famous statement: ‘All the people filling the street are sages.’ For Wang, becoming a fully moral agent is simple and easy. ‘Just don’t try to deceive it but sincerely and truly follow in whatever you do. Then virtue will be perceived and evil will be removed.’ According to Wang, we cannot unify knowledge and action because they are already unified. Knowledge automatically leads to action. For Wang, knowledge means knowing how to respond to a given situation and action is responding to a given situation. Given that one innately has knowledge of how to act in all situations, and that one cannot help acting, knowledge necessarily leads to action. When knowledge and action appear to be separate, it is because one has not activated one’s true knowledge – a result of delusion due to selfish desire or false learning. Those who distinguish knowledge and action ‘separate knowledge and action into two distinct tasks to perform and think that one must first know and only then can one act’. As a result, they become nothing more than pedantic bookworms, who study ethics without ever living up to its ideals or trying to achieve positive change in the world around them. The current teaching regarding ‘the unity of knowledge and action’ is a medicine directed precisely at this disease.

Interventional neuroradiology

Adoption of the ‘unity of knowledge and action’ philosophy in INR results in a perfect combination of individual clinical expertise and the best external evidence. Best available external clinical evidence is clinically relevant research, often from basic sciences, but especially from patient-centred clinical research. Transforming evidence into clinical practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This is especially true when dealing with INR. Much of the daily clinical practice in the field of INR is not supported by randomised trials and meta-analyses.⁴ This is not an expression of low research activity within this field, but rather an expression of the difficulties in designing meaningful trials that reflect daily clinical practice, due to the great variability of INR diseases, e.g. differences of diseases, neurovascular anatomy, patient selection, materials, techniques and treatment modalities. In this context, sharing knowledge on clinical practices (tips and tricks) between practising INR becomes especially important, and the most effective way that tips and tricks can be promoted to an academic sphere is through the international exchange of knowledge. It is here that the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) plays a significant role, by making forums for the transfer and development of clinical expertise. Appreciating that this transfer of ‘tips and tricks’ is especially important for neurovascular disease, organisations like WFITN have devoted much energy to arranging international fellowships, observerships, courses, workshops and master classes, effectively to disseminate new developments for the benefit of patients worldwide. However, the use of tips and tricks technology ultimately also needs to be evidence based, because when asking questions about therapy clinicians should try to avoid anecdotal approaches, as these often lead to false-positive conclusions about efficacy. In this respect, international organisations are crucial, by connecting clinical experts and trainees in a developmental atmosphere, creating opportunities for controlled multicentre studies to answer questions that cannot be answered through single-centre studies. In this way training might be academic and with an evidence-based perspective; the important factor is integrating individual clinical expertise and the best external evidence. For this integration, the international organisations have a special responsibility in the training of INR.

Mentoring

Convincing residents about the importance of becoming more involved in the INR procedures and patient care by placing a little bit of extra effort can yield dispropotionately better results both for the patients’ wellbeing as well as the residents’ learning. Encourage and foster younger colleagues to take up areas with less conflict as described in the ‘blue ocean strategy’, that is moving from the red ocean of fierce competition to a blue ocean area that is unexplored until the present date.

Onyx embolisation of arteriovenous malformation (AVM) is an example. AVM embolisation using onyx for a long time via a single supplier may result in long reflux and venous outflow occlusion, which is preferable for dural arteriovenous fistulas. Many occurrences of ‘injection-reflux-injection’ will result in premature draining of vein occlusion and long reflux, which causes AVM rupture and neurological deficits (Figure 1). We prefer nidus embolisation via multiple supplier catheterisation, which results in complete occlusion of the AVM with a low risk (Figure 2). This concept is based on the AVM nidus consisting of different parts of suppliers and the compartmental conceptualisation theory has been investigated.

Figure 1.

Schematic illustration showing that onyx occludes the venous outflow of arteriovenous malformation while it permeates from one part to another part.

Figure 2.

A case of cerebellar arteriovenous malformation (AVM) was occluded by onyx after four catheterisations. (a) left vertebral artery angiogram after the first session embolization through the right posterior cerebellar artery and the right anterior inferior cerebellar artery; (b) right vertebral artery angiograms showing the AVM completely embolised after the second session of embolization through two branches of the right superior cerebellar artery; (c) fluoroscopic image showing the onyx cast.

Conclusion

The ‘unity of knowledge and action’ helps us to learn from failure and successes, learn from mistakes of predecessors and institute a behaviour that prevents repetition of these mistakes. The ‘unity of knowledge and action’ helps to improve the academic atmosphere and prepare for the future.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Note

*Wang Yangming (31 October 1472 to 9 January 1529) was a Chinese idealist neo-confucian philosopher, official, educationist, calligraphist and general during the Ming dynasty.