Medical Decision-Making: Knowledge vs Wisdom

Aaron Falchook, MD

There is an important distinction between knowledge and wisdom. Knowledge refers to information that is available to a person. Wisdom can be defined as the ability to make correct judgments and decisions. Unlike knowledge, wisdom is not easily quantified or measured and may be especially elusive when needed most. Knowledge is often a necessary prerequisite for wisdom, although knowledge alone is almost never sufficient to achieve wisdom.

In the field of oncology, we are fortunate to possess a vast and ever-expanding trove of knowledge. Results from hundreds of clinical trials inform our treatment of common malignancies, such as breast, prostate, and lung cancers. There is certainly more work to do and many questions are still unanswered. However, we now have a sufficient foundation of knowledge in many cancers to afford ourselves the luxury of striving to seek wisdom as well.

Let’s take breast cancer for example. Published meta-analyses give precise, risk-factor specific details that quantify the benefits of post-lumpectomy radiotherapy (10,801 women in 17 randomized trials) and post-mastectomy radiotherapy (8,135 women in 22 randomized trials). For those who prefer to not reference detailed tables from meta-analyses, a web-based nomogram supported by peer-reviewed research is also available to more easily quantify the risks and benefits of various treatment strategies. However, these nomograms and meta-analyses cannot provide us with the wisdom that is an essential tool for decision-making.

If I am counseling a younger woman with breast cancer about the benefits of post-lumpectomy radiotherapy, I can describe that for patients with similar characteristics studies show that post-lumpectomy radiotherapy reduces the risk of breast cancer recurrence from 30%–40% to 10%.

What about another scenario? Let’s consider an older woman with a low-grade, hormone receptor–positive tumor. Evidence demonstrates that in this scenario, radiotherapy reduces recurrence risk from approximately 10% to 2% (Hughes et al). While an 80% relative reduction is still significant, an absolute benefit of 8% is more difficult to interpret. How can a physician or patient be expected to know if an 8% benefit is worth the toxicity, risks, costs, and inconvenience of radiotherapy treatment? It is wisdom in addition to knowledge that will hopefully tip the scales to the correct choice for that patient. Another important characteristic of wisdom is variability. Knowledge is concrete: a definitive answer to a specific question that is not subject to a different answer based on who is asking the question. Conversely, wisdom may lead to multiple correct answers depending on who is asking the question and where that person’s values and priorities are.

We must also consider the role of wisdom in decision-making on a population level. The growing field of health services research in large part seeks to quantify wisdom so that it can be broadly applied to our healthcare system. Tools such as quality-adjusted life years (QALY) and incremental cost-effectiveness ratio (ICER) are used by health services researchers in an attempt to quantify value in healthcare so that we can best allocate limited healthcare resources. Even with these tools, however, wisdom is required to make the ‘correct’ decision. For example, as a society, if a treatment costs $50,000 per QALY, should it be considered cost-effective? What about $75,000 or $100,000? There is no knowledge-based objective manner to answer these questions, and as such, we find ourselves dependent on the elusive element of wisdom to make these difficult choices. As our knowledge regarding treatment options for cancer continues to exponentially grow, we must take steps to ensure that our wisdom keeps pace as well.