Is a Hot Dog a Sandwich? Using Lateral Thinking to Teach Philosophy of Science

Getting Stuck With Vertical Thinking

It was day 3 of a 2-week medical education elective with internal medicine and internal medicine-pediatrics (med-peds) residents. The elective is intended to stretch residents’ thinking and spark curiosity, dissonance, and excitement by exploring education topics that often get left out of many residents-as-teachers programs. I had introduced the idea that one’s worldview includes implicit assumptions about reality (ontology) and knowledge (epistemology) that shape how one teaches, the questions one asks, and how one understands the world.^2,3 My goal was not to cram an entire course on philosophy of science into a single elective, but rather to crack the door open to new ways of thinking about science. Seated in a semicircle around a small conference room, the residents’ furrowed brows and puzzled expressions betrayed their skepticism and confusion.

“I don’t understand. You’re saying objective reality isn’t a thing?” said one of our brightest residents in a quizzical tone.

“Well, sort of,” I replied, staring at the skeptical faces of 10 residents. “Depending on your worldview, and what you’re talking about, there may be no objective reality.”

Myriad worldviews are used in medical education,³ but to simplify the discussion, I focused on 2 that are commonly used in education scholarship: post-positivism⁷ and constructionism.⁸ Post-positivism presumes that there is an objective truth in the world, though one may never be able to fully know truth given limitations of measurement and inquiry. Constructionism, on the other hand, presumes that reality and truth are not objective and “out there in the world,” but socially created by and between people. The residents intuitively understood post-positivism, but they struggled with constructionism. To open everyone’s thinking to more constructionist worldviews, we discussed published manuscripts focused on concepts that exist in the social rather than physical world, such as empathy and burnout, and began to debate whether objective reality or truth relating to these concepts exists. However, the fact that numerical scales have been used to quantify and measure both empathy⁹ and burnout¹⁰ created a veneer of objectivity for the residents. I was still struggling to help the residents consider a worldview other than post-positivism, and none of my examples were helping.

This type of educational impasse can lead to frustration for learners,¹¹ but it is an expected part of learning philosophy of science. I was asking residents to consider other ways of understanding truth and knowledge, which may require new and different ways of thinking. Much of clinical medicine and the clinical research that informs it is decidedly post-positivist in nature.⁵ Objective truth is venerated. Unless a physician has a background in qualitative research or the social sciences, they often struggle to understand how truth or reality can be socially constructed rather than objective. More explanation and logic (ie, vertical thinking) would not get us unstuck; we needed something different to jar us loose.

Getting Unstuck With Lateral Thinking

After a long pause, one of the med-peds residents asked, “So, it’s kind of like asking if a hot dog is a sandwich, right?”

“What do you mean? Tell me more.” I said.

“Well, a hot dog has some characteristics of a sandwich, but it’s not classically considered a sandwich. So, is it technically a sandwich, or not? How do we find the answer? Is there an objective answer?”

And with that, the residents were engaged in heated discussion. What is the essence of sandwichness? Is it a holistic judgment or can it be reduced to a checklist of attributes? How different are 2 slices of bread vs a hot dog bun, and are they essentially the same thing if the bun splits down the middle? If a hot dog is a sandwich, then what about tacos, hot pockets, empanadas, or corn dogs? Then comes the most important part: Is there any objective truth about sandwichness or is it socially constructed? And what are the implications of taking one view or the other?

One provocative question unlocked the whole session. Why?

In 1967, Dr Edward de Bono introduced the concept of lateral thinking,^12,13 which involves moving away from logical and linear thinking to more imaginative and creative approaches.¹⁴ With lateral thinking, “…established cognitive patterns are deliberately disrupted and information is processed differently, increasing the chances of arriving at novel perspectives.”¹⁵ Lateral thinking is a deliberate way of handling information or approaching questions with the goal of spurring creativity, generating new insights, and creating aha moments.¹⁵ For philosophy of science, lateral thinking can help disrupt a learner’s default way of seeing the world and invite openness to different paradigms.

Rather than a singular approach or checklist, lateral thinking provides a series of tools that can be used to find new perspectives.^12,14 The question posed by the resident in this story leveraged several such tools. First, the question served as a provocation,¹⁵ calling the learners to engage in a creative thinking activity. Second, it used random input,¹⁵ a stimulating question that is unrelated to the topic at hand. Hot dogs and paradigms rarely enter the same discursive space. Third, the question allowed for exploration of a useful analogy. Learners can find movement in their thinking around an analogy before relating it back to the philosophy of science or other challenging topics. Multiple strategies to promote lateral thinking are available (see the Table for a sample),^12,15 all seeking to nudge one into new ideas and lines of thought.

Table Sample Strategies to Promote Lateral Thinking With Examples of Potential Applications in Medical Education

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Lateral thinking is not a panacea in teaching philosophy of science, nor does it replace or supersede vertical thinking. However, it is a useful and fun way to help learners step out of their implicit paradigms to learn other ways of seeing the world. It can also be used in multiple other aspects of medical education, such as using the trolley problem to catalyze discussions around medical ethics¹⁶ or using immersive games to help explore bias and inequity in medical education.¹⁷ By opening space for creativity and exploration, lateral thinking can help learners challenge assumptions and broaden perspectives.

Postscript

Readers may be wondering if a hot dog is, indeed, a sandwich. There is no widely accepted answer to this question. The National Hot Dog and Sausage Council says hot dogs are not sandwiches, stating, “Limiting the hot dog’s significance by saying it’s ‘just a sandwich’ is like calling the Dalai Lama ‘just a guy.’”¹⁸ Some governmental bodies have weighed in, such as the state of New York, which classifies hot dogs as sandwiches for taxation purposes.¹⁹ The late chef Anthony Bourdain stated he did not think hot dogs were sandwiches, though in fairness he did not believe hamburgers were either.²⁰ For what it’s worth, the residents in Cincinnati tend to agree with Mr Bourdain. The more important question, dear reader, is do you believe this debate gets us closer to the objective truth about hot dogs (post-positivism), or do you believe the reality of their sandwichness is socially constructed (constructionism)? The great hot dog debate rages on.