Thanks for reading the 34th edition of my sciatica newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain!
As we saw in Part 1, The Curse of Knowledge is the immense difficulty in imagining what it’s like not to know what you know.
We spend years working hard on our knowledge, piling up tiny ‘chunks’ to build great edifices. Once we know them well enough, these chunks are effortless to recall and these great edifices of knowledge just seem… obvious.
This weird amnesia makes it very hard for us to explain what we know to people who don’t know it.
So, how can we overcome The Curse of Knowledge?
Here’s a few ideas, some better than others.
Just put yourself in the listener’s shoes…?
Maybe… but the whole point of The Curse is that this is almost impossible to do. We’re like drunk drivers who don’t know they’re too impaired to drive. But, just knowing about The Curse is a start!
Simplify… then simplify again.
If you are anything like me, when you simplify things for someone you hear a little voice in your head saying ‘Stop, you’re being patronising’. I think it’s good to ignore this voice and double down! Keep simplifying! It’s not about insulting the listener’s intelligence, it’s about being aware of your own shortcomings in your ability to understand their perspective.
(Sometimes, to allay my fears of being patronising, I say something like ‘I think you probably know this already, but just so we’re on the same page…’)
I try to make it a point of pride to make my explanations as simple as possible. After all, it takes a lot of skill and effort to make things simple. It’s a bit like how Dolly Parton once said ‘You wouldn’t believe how much it costs to look this cheap’.
For example, before I explain what radicular pain is, I often take a bit of time and effort to explain what a nerve is, and how normal sensation works. ‘A little signal starts here and goes up into your spine and up to your brain…’
And here’s a few nice simple words that help when explaining nerve root syndromes: squashed, pressed on, crowded out, prodded, nudged, bothered, irritated, inflamed, sore, pissed off, angry, red, swollen… Sometimes I feel silly saying these words, or worry that they don’t convey enough accuracy or nuance. But most of the time, it’s worth it if it helps the patient to make sense of the chaos.
If you are concerned that when you simplify your explanations they lose accuracy, consider that simple and technically inaccurate understandings can still be useful, often more so than more complicated, accurate ones. For example, borrowing an example from Chip and Dan Heath, it’s likely that when you were a child you were taught that in an atom, electrons revolve around the nucleus like planets around the sun…
…When in fact (apparently!), electrons move around an atom’s nucleus in something called probability clouds…
I don’t understand that picture at all, but that’s the point. The more simple solar system model of an atom, although technically incorrect, has been useful enough for me to get through life so far. And if I had ever needed or wanted (or been smart enough) to know more about physics, it would have been a stepping stone on the way to the more accurate ‘probability cloud’ model.
So when I’m simplifying something and I find myself worrying that I’m being inaccurate, I remind myself that a lot of my own understanding of the world is technically inaccurate but ‘good enough’.
Be visual, be physical.
Although we use words to label our chunks of knowledge, the process of learning them isn’t only verbal, but to a large extent visual and physical. Before you got a good chunk for ‘sciatic nerve’ you probably looked at them on diagrams, palpated and traced them out on your partner in practicals, and tested what it felt like to tension them on yourself. We are just primates and big parts of our brains are dedicated to vision, touch, motion and space.
So don’t skip these visual and physical steps when helping patients understand what you already know. Of course this means showing them diagrams, but also touching them and helping them move their body as you are explaining things, assuming it feels appropriate (does that count as manual therapy?). Let’s say you are explaining what a nerve is, and how sensation works; as you do this, you could put your hand on your patient's calf, for example, saying ‘when I touch you on the calf like this, a little signal goes up…’, and as you do so you can literally trace the signal up to their brain. Same for explaining ectopic impulses from the nerve root.
This doesn’t all have to be in one ‘education session’ after your assessment. A good time is often the neuro exam. Or while you are doing your slump or straight leg raise tests, when you can help your patient to get an understanding of their nerves and in what positions they are tense or slack.
Oh, and the importance of vision and touch also likely means the much-maligned spinal model should make a comeback…
Tell a story!
Remember the string of letters from part 1 that became memorable once made them into chunks: MD, PHD, RSVP, CEO, IHOP? That string becomes even more memorable if we make it into a story: The MD and the PhD RSVP’d to the CEO of IHOP!
The best stories set the scene, then have some tension, then a resolution. Explaining acute radicular pain, we might set the scene by talking about how lots of normal, nice impulses are always travelling up from the leg to the brain… then all of a sudden a mean, nasty disc herniation arrives on the scene and the nerve root freaks out by sending up lots of crazy impulses… but if we wait long enough and stay positive, the immune system will come to our aid by mopping up the disc herniation and helping all the inflammation in the area to resolve… (and we’ll be back in The Shire, Master Frodo.)
Now, there are a hundred problems with that explanation (and I’m sure someone on twitter will let me know the most obvious ones), but you can’t say it’s not memorable and meaningful.
People understand the world through stories. Our patients are going to get their stories from somewhere; it might as well be you!
Test your explanations!
This advice is from Steven Pinker’s writing guide which, as I said in part 1, is where I first learned about The Curse of Knowledge. Pinker says that the only way to really overcome The Curse and become a better writer is to test your writing by giving it to other people to read. Or, failing that, to at least put what you’ve written in a drawer somewhere for a few weeks so you can read it with fresh eyes. Just as you can write yourself a to-do note that doesn’t make sense the next week, Pinker says you will often find that your best attempts at communicating clearly have huge flaws on second glance.
For clinicians, who are not writing but talking, Pinker’s advice means testing our explanations on our lay friends and family, or recording our explanations and listening back to them with fresh ears a week or two later.
It might seem like an odd idea, but we are used to practicing our special tests on colleagues and testing out the exercises we prescribe on ourselves. Why not treat our explanations the same way?
Well that’s it for my little Curse of Knowledge interlude… normal service will resume next time. I’m really curious to hear your thoughts on the last two newsletters (and as always, especially if you disagree), so do reply and let me know!
Til next time,
P.S. Here’s a little tip that didn’t really fit anywhere else in the newsletter. When you want to check your patient’s understanding, you might find yourself asking ‘Does that make sense?’. This puts the onus on your patient to understand; in effect, the implied question might seem to be ‘Does that make sense to you, or can’t you keep up?’ Instead, a better question might be ‘Am I making sense?’. This puts the onus on you; the implied question is ‘Am I making sense, or do I need to do better?’
P.P.S. I have received some complaints, and I want to apologise for using the word ‘chunks’ so many times. Trust me, I tried not to. Pinker uses it non-stop in his book, including the unforgettable phrase ‘An adult mind is brimming with chunks’ 🤢