By Evan Falchuk

Last Sunday’s New York Times Magazine had a fascinating essay by Michael Crawford.  Crawford quit his high-paying job at a DC think tank for a new career as a motorcycle mechanic.  The essay talks about his journey, and the insights he gained from the art of working with his hands.

He’s most interesting when he describes what it’s like to think about complicated problems.  It reminded me a lot of things I often hear from doctors on how they think about medical problems.

Crawford says:

In fixing motorcycles you come up with several imagined trains of cause and effect for manifest symptoms, and you judge their likelihood before tearing anything down. This imagining relies on a mental library that you develop. An internal combustion engine can work in any number of ways, and different manufacturers have tried different approaches. Each has its own proclivities for failure.

And doesn’t this sound like a doctor describing one of the pitfalls of clinical protocols or evidence-based medicine?

There probably aren’t many jobs that can be reduced to rule-following and still be done well. But in many jobs there is an attempt to do just this, and the perversity of it may go unnoticed by those who design the work process. Mechanics face something like this problem in the factory service manuals that we use. These manuals tell you to be systematic in eliminating variables, presenting an idealized image of diagnostic work. But they never take into account the risks of working on old machines. So you put the manual away and consider the facts before you. You do this because ultimately you are responsible to the motorcycle and its owner, not to some procedure.

Some diagnostic situations contain a lot of variables. Any given symptom may have several possible causes, and further, these causes may interact with one another and therefore be difficult to isolate. In deciding how to proceed, there often comes a point where you have to step back and get a larger gestalt. Have a cigarette and walk around the lift. The gap between theory and practice stretches out in front of you, and this is where it gets interesting. What you need now is the kind of judgment that arises only from experience; hunches rather than rules. For me, at least, there is more real thinking going on in the bike shop than there was in the think tank.

Well, ok, a doctor probably isn’t going to smoke a cigarette while he thinks about your medical problem.  But Crawford’s talking about a profound kind of thinking that most of us can’t really do.

Anyway, Read the Whole Thing.