Epiphanic Thinking

There is a concept, which I call “epiphanic thinking,” that belongs in the same epistemological category as intuition and tacit knowledge. All three terms refer to a kind of knowing that is not arrived at by analytic reasoning, and that is often difficult to articulate or even to understand. Whereas intuition and tacit knowledge can be either gradual or sudden, epiphanic knowing is abrupt and total, a kind of awareness that is experienced as a flash of insight or a sudden recognition.¹⁴

Marx Wartofsky in his essay on clinical judgment and cognitive style calls it variously “a revelatory moment,” “catching on,” “the ‘aha’! moment,” and a “gestalt click.”¹⁵ It could also be called a “eureka” experience, recalling the story of Archimedes, who, while bathing, suddenly realized the solution to a problem, whereupon he ran out into the street, naked, shouting “Eureka! (I have found it!).”

Epiphanies in medical practice can range from an intuition about a specific patient to a general insight about death or birth or aging. Internist Rita Charon observes: “The hesitant glance, the inarticulate sigh, or, as William Carlos Williams says, ‘the hunted news I get from some obscure patients' eyes’ carry with them profound challenge about the meaning of lives and the meaning of deaths.”¹⁶

Such epiphanic recognition of meaning—even if that meaning cannot be articulated—is an important dimension of a physician's competence. This kind of knowledge is similar to what Michael and Enid Balint, in their seminars with general practitioners at the University College Hospital in London, called “the flash” or “the flash technique”—“an intensity of observation, of identification, and of communication” between patient and physician.¹⁷

Epiphanic knowledge can be thought of as an aspect, a dimension, of narrative knowledge.¹⁸

One way to conceive of this relation is to think of narrative as moving through nodes of the epiphanic—moving toward, and then away from moments of insight and recognition. But it is also true that epiphanic knowledge contrasts in certain ways with narrative knowledge. Whereas narrative configures experience as linear and progressive, representing it as the unfolding of a process through time, the epiphanic is sudden, immediate, and total. Moreover, narratives can be told, heard, and understood; for the most part, a narrative is or can be explicit. But the epiphanic refers to a dimension of knowledge that cannot quite be articulated—either to oneself or to others. Certainly, the narrative approach to medicine and to ethics will be enriched by a better understanding of how epiphanies function.

Why is the idea of epiphanic knowledge important? Because it focuses on a kind of thinking that occurs fairly often in clinical practice—especially in regard to diagnosis, to doctor–patient interactions, and to ethical decisionmaking. Skilled physicians are attentive not just to what a patient says, but also to tone of voice, body language, facial expression, and so forth. Such physicians know that the offhand phrase or the elliptical comment can yield knowledge as significant as the explicit narrative account that the patient constructs during the clinical interview. This attentiveness was studied in an essay by Branch and Malik about “windows of opportunities” in the clinical encounter,¹⁹

and in another essay by Wendy Levinson and others about physician responses to patient clues.²⁰

Branch and Malik find that many patient interviews are punctuated with episodes of strong emotion on the part of the patient—these are the “windows of opportunities” that the physician either responds to or does not respond to. When the physician does respond, usually by attentive silence, there is an epiphanic moment between patient and doctor.²¹

The essay by Levinson et al. describes something very similar, though with a much larger patient base. These authors find that patients frequently offer “clues” or hints during an interview about some aspect of their inner world, which the physician either responds to or else ignores. Responding to these clues deepens the therapeutic relationship and potentially enhances clinical outcomes.²² In both essays, the authors observe that, overwhelmingly, physicians tend to miss these windows of opportunities or patient clues—perhaps because they did not even recognize them.

The intuitive skills that are so obvious in diagnosis and in patient interaction also play a part in ethical decisionmaking. Bioethics is sometimes criticized for too narrow a focus on certain types of ethical problems—namely, problems that have solutions; problems that can be dealt with by analytic thinking. But ethical issues today are plentiful and widespread. Indeed, Rita Charon and Leon Kass declare that there are ethical issues embedded in every encounter between a doctor and a patient.²³

Recognition of ethical problems is itself an important step in the ability to practice ethical medicine.²⁴ Physicians who are aware of the epiphanic dimension of their work—the profound but often latent meanings in ordinary interactions with patients—will be better able to recognize ethical issues in the day-to-day practice of medicine.

Epiphanies in Literature

The word epiphany comes from the Greek epi, meaning on or above, and phainein, meaning to show or to manifest. An epiphany, then, is a showing forth of some kind. Its original usage in the English language referred to a Christian festival observed on January 6: the revelation of the infant Christ to the Magi for the Roman Church and the baptism of Jesus for the Orthodox Church. But during the 20th century the term underwent a rigorous secularization, becoming a widespread literary device.²⁵

Today, then, an epiphany is simply any sudden and important realization. The term is now a staple of contemporary literary fiction and is often alluded to in the pages of the New York Times Book Review or the Times Literary Supplement.

Epiphanies of various sorts can be found in literary works from all eras. Because literary epiphanies occur in a wide range of literary genres from different cultures and different historical eras, it seems likely that epiphanic ways of knowing and perceiving are a part of the way the human mind works. The spectrum of epiphanies in literature ranges from recognition to revelation, from realizations that are human discoveries of self or other to occasions when life seems to reveal itself in some numinous moment. Perhaps an examination of particular literary works can help us better understand what epiphanic knowledge is, as well as clarify the relationship of the epiphanic both to tacit knowing and to narrative knowledge.

In ancient Greek literature, as in the Christian tradition, epiphany refers to manifestations of the divine. Thus, throughout Homer's Iliad, gods appear to mortals, often as epiphanic representations of the meaning and consequences of human actions. A good example of this kind of epiphany comes at the very beginning of the Iliad. Achilles becomes so angry at Agamemmnon that he begins to draw his sword, intending to run him through. Suddenly, though, the goddess Athena intervenes to stop him, coming out of nowhere to stand behind him and tugging at his hair so that he turns around, recognizes her, and thrusts his sword back into its scabbard.²⁶

Nowhere in the narrative is there any indication that Achilles “changes his mind”; rather, the whole action is subsumed in an epiphany that represents (rather than describes) Achilles' sudden awareness of the nature and consequences of his intended action.

Today, of course it is not likely that a divinity will appear (either in literature or in life) to resolve conflicts and show us the meaning of our intended actions. However, we have all experienced moments when we have a sudden feeling or monition about a person or an intended action that seems to come from nowhere. This kind of experience is mentioned on occasion by medical professionals. For example, Lisa Ruth-Sahd observes, in an essay in Nursing Education Perspectives: “Nurses often will report having an ‘uneasy, gut feeling’ about a patient, stating, for example, ‘I could tell he was going to code when he walked in the door’.”²⁷

Another example is internist Lisa Sanders, who remarks, in a recent New York Times Magazine article: “When we teach residents and medical students, we teach diagnosis as if it were a methodological process that moves from symptom to disease identification in a thorough, careful and logical manner. But the best diagnosticians often move from presentation to diagnosis in an instant, bypassing the reason and logic with an almost instantaneous recognition of the pattern of the disease.”²⁸ Of course it is true that the nurse's patient may not code, and the superb diagnostician Sanders alludes to could be just plain wrong in his or her diagnosis. Important decisions should never be made simply by relying on hunches and intuitions. Epiphanic knowledge needs to be checked against and integrated with other ways of thinking and knowing.

Though epiphanies recur throughout literature from all eras, it was James Joyce who first articulated (and secularized) the concept of the literary epiphany. By epiphany, he meant a sudden revelation of a person's true character or the sudden understanding of the meaning of an event.²⁹

Such things have a kind of radiance, Joyce would say. Epiphanies for Joyce always concerned commonplace, prosaic, and trivial events in ordinary life. He believed that a part of the artist's mission was to foreground epiphanies, looking for them not in lofty themes and subjects but in casual and commonplace events. An epiphany in one of his stories might be the single word that suggests a much wider meaning or the simple gesture that reveals a complex set of relationships.

The Joycean epiphany can be positive or negative, and can be about oneself, about another person, or about an event. The stories in his collection, Dubliners, are thought by literary critics to be organized around one or more epiphanies. In “Araby,” a young boy comes too late to the bazaar of which he has dreamt all day and finds the big hall nearly empty: “Gazing up into the darkness I saw myself as a creature driven and derided by vanity; and my eyes burned with anguish and anger.”³⁰

But it is not always the protagonist who experiences the epiphany. In “Clay,” Maria, the pathetic spinster aunt, blindfolded in a game of lots, chooses “a soft wet substance,” the clay that reveals to the onlookers, though not to her, that she is going to die.³¹ In the final and culminating story of Dubliners, called “The Dead,” Gabriel Conroy catches sight of his wife standing in the shadows near the stair top and listening rapt to a plaintive Irish song: “There was grace and mystery in her attitude, as if she were a symbol of something.”³² This partial and romanticized epiphany leads to other revelations that help explain the “mystery,” for the song Gretta hears reminds her of the young man who sang it, and who loved and died for her. But this discovery awakens in Gabriel a sense of an all-encompassing mortality, prompting the visionary epiphany of falling snow with which the story and the whole collection ends.³³

William Carlos Williams transposes the Joycean epiphany to a medical context in stories where his fictive counterpart—the testy and irascible Dr. Williams—suddenly understands a child's condition or family background. One thinks of his epiphanic understanding of the overly attentive immigrant mother and her husband near the end of his story, “A Face of Stone,” where Williams observes: “Suddenly I understood his half shameful love for the woman and at the same time the extent of her reliance on him. I was touched.”³⁴

In his Autobiography, Williams connects his literary activity to the epiphanies he experiences in the day-to-day quotidian details of practicing medicine; thus he refers to those moments in his work “when we see through the welter of evasive or interested patter, when by chance we penetrate to some moving detail of a life…. just as it comes in over the phone or at the office door…. [w]e catch a glimpse of something, from time to time, which shows us that a presence has just brushed past us, some rare thing.”³⁵

A third and strikingly different literary example of the epiphanic is haiku—a brief, unrhymed verse form that originated in 17th-century Japan. Because of its brevity and the fact that it focuses on a single image, any given haiku must be perceived and understood all at once, immediately and totally, without analytic, discursive mental processing. Like other forms of epiphany, haiku do not lend themselves well to paraphrase or analysis—they are understood subceptively, to use Polanyi's term.³⁶

Zen patriarch Hui-neng is often cited as having remarked that to write haiku, one should strive to look not “at” but “as” the object or event.³⁷ Hui-neng's aphorism is remarkably similar to Polanyi's description of tacit knowing as a mental process that integrates, subceptively, various levels of awareness; as an act of indwelling; as a “from–to” kind of knowing where, in a single mental act, one looks from a thing to its meaning and thereby interiorizes it.³⁸

The state of mind required to write as well as read haiku with full understanding is often referred to as a “haiku moment”—an immediate, epiphanic apprehension of some particular aspect of experience that is felt to be deeply true; a peculiar kind of clarity that some call “ah-ness,” because the experience or poem evokes the response, “Ah, now I see.” The following two examples are both about the season of autumn: The author of the first is the late 17th-century Japanese poet known as Basho; the second is by Buson, who flourished in the mid-18th century.

The act of reading the poem fully conveys its meaning: No subsequent act of interpretation or analysis is required.

Reading and writing haiku offers a way to train the intuitive mind. I have found that haiku is useful in teaching medical students how to recognize tacit knowledge and even how to produce the state of mind that facilitates intuitive thinking and tacit knowing. Students find that reading and writing haiku hones their listening skills, making them not only more comfortable with being silent, but also more appreciative of the deep communication that can occur during times of silence.