How the Brain Learns Without Conscious Awareness

In an era when medicine increasingly measures itself in algorithms, biomarkers, and machine-readable data, a newly published essay in the Journal of General Internal Medicine invites clinicians and patients alike to reconsider a quieter, harder-to-quantify form of medical knowledge: the kind that operates beneath conscious awareness. The piece, titled “Knowing Without Knowing,” appears in the journal’s Healing Arts section, a venue dedicated to narrative, reflective, and humanistic writing on medical practice, and was authored by Nadeem Jones, BA, of Columbia University Vagelos College of Physicians and Surgeons. Published on August 31, 2026, the essay arrives at a moment when the medical profession is engaged in an intense debate about the respective roles of explicit, evidence-based reasoning and the tacit, intuitive understanding that experienced clinicians often describe but rarely teach.

The Healing Arts section of the Journal of General Internal Medicine occupies a distinctive position within the medical literature. Unlike original research articles that report trials, cohort studies, or systematic reviews, the section publishes personal essays, literary reflections, and narrative medicine pieces that explore the lived experience of illness and caregiving. These contributions do not test hypotheses in the conventional sense. Instead, they function as a form of professional self-examination, asking physicians, trainees, and patients to articulate dimensions of medical practice that standardized measures struggle to capture. Jones’s essay, according to the journal’s published record, was received on June 2, 2026, accepted on August 6, 2026, and carries no external funding, positioning it squarely within the tradition of individually driven reflective writing that has become an important counterweight to medicine’s increasingly computational self-image.

The title itself—Knowing Without Knowing—gestures toward one of the most actively discussed concepts in contemporary clinical epistemology: tacit knowledge. The term, popularized in the twentieth century by the philosopher and scientist Michael Polanyi through his famous dictum that “we know more than we can tell,” refers to understanding that guides action without being fully articulable. In medicine, tacit knowledge shows up in the seasoned internist’s sense that something is “off” about a patient whose vital signs and laboratory values are technically normal, in the emergency physician who redirects attention based on the way a family sits in a waiting room, and in the surgeon whose hands adjust to tissue resistance in ways no textbook can fully specify. Jones’s essay engages this territory from the vantage point of medical training, a stage of professional life when the gap between what students are formally taught and what practicing clinicians actually do becomes impossible to ignore.

Modern medical education is, by design, overwhelmingly explicit. Students memorize diagnostic criteria, learn to apply validated clinical prediction rules, and are drilled in structured reasoning frameworks that break the diagnostic process into discrete, auditable steps: gather data, generate a differential diagnosis, order tests to discriminate among hypotheses, and revise accordingly. This explicit architecture exists for good reasons. It makes reasoning transparent, allows errors to be identified and corrected, and supports the evidence-based medicine movement that has transformed patient care over the past three decades. Yet research in cognitive psychology and clinical decision-making has repeatedly shown that expert clinicians do not primarily work this way. Studies of diagnostic reasoning distinguish between analytical, System 2–style deliberation and the faster, pattern-recognition-driven processing often labeled System 1, and decades of work—most prominently by researchers such as Geoffrey Norman, Eva Midler, and colleagues studying diagnostic expertise—suggest that experienced physicians rely heavily on non-analytic reasoning built from accumulated exemplars. The expert “sees” the diagnosis, in a sense, before being able to explain how.

This is where reflective essays like Jones’s perform intellectual work that conventional research articles cannot. A randomized trial can determine whether a diagnostic algorithm improves outcomes, but it cannot capture the phenomenology of clinical intuition—the felt sense of knowing that precedes justification. Narrative accounts allow trainees and practitioners to describe these episodes honestly, including their epistemic discomfort: the clinician acts on a hunch, cannot fully defend it, and must decide whether to trust it. Cognitive scientists have long noted that such intuitions are double-edged. The same rapid, automatic processing that enables expert pattern recognition also produces the heuristics and biases—anchoring, availability, premature closure—that fuel diagnostic error. The debate over dual-process theories of clinical reasoning, carried on for years in journals such as Academic Medicine and Diagnosis, turns in large part on this tension: intuition is simultaneously the hallmark of expertise and a documented source of preventable harm.

The timing of the essay is notable. As large language models and clinical decision-support systems are embedded into electronic health records, the question of what counts as medical knowing has acquired new urgency. Proponents of artificial intelligence in medicine argue that algorithmic tools can standardize judgment, reduce variability, and catch what human attention misses. Critics counter that these systems, however powerful, operate on entirely different epistemic foundations from human expertise. A machine-learning model may identify statistical regularities in vast datasets, but it does not inhabit the room with the patient, register the hesitancy in a voice, or carry the embodied memory of a thousand previous encounters. Jones’s meditation on knowing without knowing speaks directly to this divide, reminding readers that a substantial portion of clinical competence has always been invisible, internal, and resistant to formalization—and that any attempt to fully externalize medical judgment must reckon with what it leaves out.

Narrative medicine, the interdisciplinary movement associated with Columbia University and figures such as Rita Charon, has argued for decades that close reading, reflective writing, and attention to story are not decorative additions to clinical training but essential tools for developing the very capacities that explicit curricula neglect: empathy, attention, tolerance for ambiguity, and awareness of one’s own cognitive and emotional states. Essays published in Healing Arts-style sections function as both practice and product of this approach. By writing about an experience of knowing that resists articulation, the author performs a kind of epistemic honesty that the clinical record rarely permits. Medical charts document what was ordered and what was found; they do not document the clinician’s uncertainty, the flash of recognition, or the slow accumulation of unspoken understanding that shaped a decision.

For patients, the significance of this literature is more than academic. Public understanding of medicine often oscillates between two poles: the fantasy of omniscient, all-knowing physicians, and the fearful suspicion that medicine is mere guesswork. Reflective writing offers a more accurate middle picture. Clinicians do know things—often a great deal—but part of what they know is procedural, embodied, and experiential, and part of their work is done in genuine uncertainty. Research on clinical uncertainty, including qualitative studies of how physicians communicate doubt to patients, suggests that acknowledging the limits of explicit knowledge, rather than concealing them, can strengthen the therapeutic relationship. An essay like “Knowing Without Knowing” gives both clinicians and patients a vocabulary for this middle ground: the recognition that some of the most consequential medical judgments are made in the space between data and intuition, and that honesty about that space is a feature of good medicine, not a defect.

The institutional context of the publication also merits attention. The Journal of General Internal Medicine, the official journal of the Society of General Internal Medicine, has long supported humanities scholarship alongside rigorous health services research, and its Healing Arts contributions are frequently used in medical school seminars on reflection and professionalism. The essay, authored while its writer is affiliated with Columbia’s Vagelos College of Physicians and Surgeons, exemplifies a growing trend of trainee-authored reflective work in high-profile journals. Encouraging students and residents to publish narrative pieces serves multiple purposes: it develops their capacity for self-scrutiny, contributes to a shared professional literature on the experience of medicine, and signals to the next generation of physicians that reflective capacity is a professional skill rather than a private indulgence.

Whether tacit clinical knowledge can ever be fully taught remains an open question. Some educators argue that structured reflection, deliberate practice with feedback, and exposure to large numbers of patient encounters gradually convert the inarticulate into the teachable. Others maintain that a residue of knowing will always escape formal instruction, passed instead through apprenticeship, observation, and stories—the very medium in which Jones’s essay is cast. What is clear is that as medicine digitizes, the genre of reflective medical writing is likely to grow in importance, serving as a record of the human dimension of clinical judgment at precisely the moment that dimension risks being squeezed out of routine documentation. “Knowing Without Knowing” takes its place in that ongoing record: a reminder, published in one of internal medicine’s leading journals, that expertise is not only what a clinician can explain, but also what a clinician knows without yet knowing how to say.