In the first article in our series about intelligence and medicine, Brian McMullen explores how doctors and medical students think and if this can affect their careers

Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?

T S Elliot, The Rock, 1928

How many different forms of intelligence can you think of? For most people, being clever is connected with success in exams. In the past, the standard measure of intelligence has been the IQ test.

In 1983, Howard Gardner from the Harvard School of Education proposed that there is not a single entity called intelligence. He suggested an idea of "multiple intelligences" (see box).¹

Multiple intelligences

• Musical or rhythmic
• Visual or spatial
• Bodily or kinesthetic
• Verbal or linguistic
• Logical or mathematical
• Interpersonal
• Intrapersonal

Others have suggested different kinds of intelligences: cognitive (IQ), emotional (EQ), and spiritual (SQ). This article is concerned with cognitive intelligence. In the next two articles I will consider emotional and spiritual intelligence and their relation to the practice of medicine. Being "clever" in the traditional sense is no longer enough.

A brief history of IQ

The word intelligence goes back to Aristotle, who distinguished "orexis," the emotional and moral functions, from "dianoia," the cognitive and intellectual function. Dianoia was translated by Cicero as intellegentia ("intra" means within and "legere" means to choose).

Ebbinghaus devised the first test of higher intellectual function in 1897. It was the French psychologist Alfred Binet, however, who produced the first practical scale for measuring intelligence, in 1905. For many years he had studied the physical and mental development of his daughters. Then the Paris education authorities approached him for help in discovering children who were "too dull" to attend normal schools.²

Binet thought intelligence was a complex set of qualities including judgment, comprehension, and reason. He also included the power of self criticism.³ In 1916 Lewis Terman of Stanford Unversity published an extensive revised version and the Stanford-Binet scale was widely used for many years. The tests were used to calculate a mental age. It was Terman who introduced the IQ (mental age divided by chronological age times 100).

This method worked for children but as the growth of this form of intelligence slows down, the system will not work for teenagers and adults. Later tests used a percentile model for these groups. Terman was an enthusiast for IQ testing and even suggested it would reduce crime and prostitution.²

Thinking about thinking

It is no coincidence that thinking functions, rational analysis, logical deductions, mathematical skills, and linguistic skills are the easiest to measure. Examinations are the tools generally used to select medical students, and pressure of work dictates that most medical students will only study aspects of work that are examinable.

Thinking can be subdivided into "closed systems" and "adventurous thinking."⁴ In a closed system the solution is predetermined (which is what IQ measures). For example, a patient presents to you with abdominal pain. Somewhere you have a series of boxes with different labels: urinary tract infection, irritable bowel syndrome, and so on. You listen to the story and ask some questions. You may examine the patient and order investigations. If the results fit into a box then you pick out the treatment from the box and prescribe it. This approach has value. If you have a belief system that says the world is stable and operates like clockwork (according to the laws of Newton) then you probably prefer this model.

This approach is
also useful in an argument. If I can prove the other person is wrong, then it shows how clever I am. Edward de Bono, a world authority on the teaching of thinking, wrote: "People tend to use thinking to parade their egos."⁵

So it may help for doctors to remember that there are "high IQ" individuals in all walks of life, and "even traditionally exalted groups such as physicians" can have individuals who would be measured as having only "normal" intelligence.⁶

It is easy to get confused sometimes between intelligence and thinking. For example, this appeared in a BMJ theme issue on exploring cooperation between doctors and nurses, "Doctor's and nurses are divided by gender, background, and--dare I say it?--intelligence (doctors are usually top of the class, nurses in the middle)."⁷

Thinking too much

Do you think too much? Many of us feel overloaded with information. An algorithm is a process or a set of rules used for solving problems. It is an excellent example of closed system thinking. Are your office walls papered with guidelines for doctors? These have a part to play as society demands more accountability from the profession. In an extreme form, however, it leads to the practice of "cookbook" medicine. Our development as individuals becomes a form of training rather than learning by experience.

Computers have wonderful cognitive intelligence. They are excellent at measurement. As doctors, we are spending more and more time in measurement. We think and talk about outcomes and quality and these are important. Should we be concerned, however, about the time spent thinking about measurement? Charles Handy, author and broadcaster, is someone who challenges us to think "outside the box." In the Macnamara fallacy he says, "The first step is to measure whatever can be easily measured. This is OK as far as it goes. The second step is to disregard that which can't easily be measured or to give it an arbitrary quantitative value. This is artificial and misleading. The third step is to presume that what can't be measured easily isn't important. This is blindness. The fourth step is to say that what can't easily be measured really doesn't exist. This is suicide."⁸

Thinking and your career

How you think will determine your career direction and also how you choose it. If you enjoy thinking and inquiring, then academic medicine might interest you. You may be attracted to specialties with an emphasis on biomedical diagnosis and curing disease. You are likely to enjoy using technology including computers.

In choosing a career you will probably first need to get information. What are the options? How are the prospects in different specialities? How do salaries compare? Does it fit with my talents and desired lifestyle? Then you might begin to analyse and argue and judge these options. You may find yourself being logical and cautious. This is fine up to a point. However, your decision may be more effective if you take account of your feelings.

If you prefer to think "outside the box" you may wish to work in a smaller, more creative organisation where your particular talents are encouraged. You may be more interested in designing solutions rather than analysis and judgment. The NHS provides a great diversity of experience. That may not be enough and you may be curious about alternative medicine, systems of health care abroad, or the private sector.

Throughout your career, treat thinking as a skill that you can constantly develop. Flexibility in thinking takes effort. The alternative, however, is to remain stuck in fixed patterns that mean you may miss all the possible solutions to life and career problems.

Postmodern thinking

So cognitive intelligence is fine, as far as it goes. If it is all you have, however, then your potential in a medical career and as a human being is limited. You could always audition for Mr Spock in a production of Star Trek.

Most of us are faced with rapid and continuous change in our working lives. How can we respond to a society characterised by uncertainty? In "adventurous thinking" there is a freedom involved and the thinker does not know if there is a final or correct solution. Exponents of this approach include de Bono, who introduced the term "lateral thinking,"⁹ and Tony Buzan of mind map fame, who described the idea of radiant thinking.¹⁰

We are now moving beyond the serial thinking that IQ tests measure. Thinking in a straight line is rather like serial processing in a computer or a conditioned reflex like a knee jerk. Developing complicated neural networks involves skills like pattern recognition and learning by experience.

You might take more responsibility for your education and personal development. Learning by experience is not always comfortable; you may have to take risks. The good news is that in this type of learning there are no mistakes, only experiments.

1. Gardner H. Frames of mind. New York: Fontana Press, 1983.
2. Vernon P. Intelligence and attainment tests. London: University of London, 1960.
3. Binet A, Simon T. The development of intelligence in children. New York: Arno Press, 1983.
4. Bartlett F. Thinking. St Leonards: Allen and Unwin, 1958.
5. De Bono E. Six thinking hats. Boston: Little Brown, 1985.
6. Richards T. Testing intelligence. BMJ 2001;323:348. (11 August.)
7. Smith R. Doctors and nurses: a new dance? [editor's choice] BMJ 2000;320. (15 April) www.bmj.com/cgi/content/full/320/7241/0
8. Handy C. The empty raincoat. London: Hutchison, 1994.
9. De Bono E. Lateral thinking. London: Penguin, 1990.
10. Buzan T. The mind map book. London: BBC Books, 1993