Lake Wobegon Medicine

If you’re a fan of Garrison Keillor and the NPR show, “A Prairie Home Companion”, you know about Lake Wobegon. Keillor’s closing words from this fictional Mid-West destination were always the same, “Well, that’s the new from Lake Wobegon, where all the women are strong, all the men are good looking, and all the children are above average.” An amusing sentiment since clearly not all of any population can be above average with respect that that population.

An average is colloquially the arithmetic middle of a collection of numbers. Precisely half of that collection is above the average (or mean), half is below. I acknowledge there are other measures of central tendency. My point, however, is that across a collection of numbers or children or physicians, not everyone can be above average. It’s just not possible.

A cited criticism of the U.S. educational system, particularly with respect to mathematics education, is the favoritism to those students who possess an innate talent for a given subject. This favoritism produces a sense that you should have no interest in subjects for which you possess no talent. Nonsense.   Being innately “below average” may indeed have some benefits. Arguably the best teachers of a difficult subject are those who have struggled with it and can show others a path toward comprehension.

“C = MD” is often cited among many in medical school and in part it is true but unlike the children of Lake Wobegon clearly there are at least some future physicians who are NOT above average among their peers. Does this matter? It can in a number of aspects but the aspect I am most interested in is that among practicing physicians there can be a sense that we’re all equal when indeed clearly this can’t be case. Honest appraisal of our talents induces humility to admit those instances where we can learn and become better or avoid and let others with better talents take over. This sort of appraisal can get really messed up. Pride, lack of reference, remuneration, time, and sloth, among other things can make appraising our talents difficult. Note I’m not saying physicians consciously avoid self-appraisal but who among us, in any context, wants to hear what we need to improve? That’s like saying you want to have your teeth cleaned – you do it because you know its good for you, not because you want to. I’m reminded of the ancient Greek aphorism, “know thyself.” There is growing pressure for physicians to “know thy outcomes” as part of reforming health care but for those efforts to work medicine needs to first acknowledge we all possess a need to know. Lake Wobegon is fiction and so too is the notion we in medicine are in every respect all above average…everyone needs to be working to be better.

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