Editor’s Note: This post was previously published in Insights on Residency Training, which is hosted by NEJM Journal Watch.
Don’t ever be afraid to say, “I don’t know.”
Those were parting words from one of my physician mentors in medical school. I had asked him for wisdom in making the transition to residency. “In my career, I’ve seen hundreds of physicians who cannot bring themselves to say those words. They are generally the ones who get burnt out. They are the ones that shout at you when you consult them over the phone. They are the ones who leave medicine, one way or another.”
My mentor’s point was to stay intellectually humble. The practical application to clinical medicine is obvious. We’ve all learned about the different types of biases that lead to medical errors and diagnostic misses. As trainees, we have seen physicians who exhibit too much hubris make mistakes.
I am reminded of my mentor’s comments now that July has arrived and a new class of interns has started their training. Their enthusiasm for residency and the pursuit of learning is a breath of fresh air. Along with the enthusiasm has come a multitude of “I don’t knows”:
- “I don’t know where to go when we start in the hospital tomorrow.”
- “I don’t know how the attending likes case presentations.”
- “I don’t know my dictation number.”
- “Can my patient eat?”
- “Can I eat?”
- “What is the best flavor of enema?”
- “Do I need an enema?”
- “She brought her service animal into the hospital, but she didn’t say it was a python.”
- “I don’t know what to do about his pain — he told me he’s allergic to everything but Dilaudid.”
Residency is endlessly humbling, but interacting with interns has shown me how much I have grown as a physician. I can answer all of the questions mentioned above, and even a few more.
One thing is getting harder to say
As my years of residency have gone by, and I have made the transition to senior resident, it has gotten harder to say “I don’t know.” Just like my mentor predicted. Not knowing things on the wards or missing something in clinic stings my pride more now than it did when I was an intern.
The most common feedback I give to medical students and interns is to be decisive with their plans. This was also the feedback I received on my own medical student rotations. I imagine it is feedback most learners receive. Being a competent clinician requires synthesizing large amounts of data and committing to a plan of action. But it is also possible to take “decisive” too far. A phrase has stuck with me:
“Sometimes wrong, never in doubt.”
A surgeon said this, while preparing to take a patient with abdominal pain to surgery for suspected appendicitis. In this particular instance, appendicitis is exactly what the patient had. It was one of those times to be decisive, and rapidly decisive. But whether through conscious effort or subconscious tendency, we often take “fake it until you make it” too far. We become insecure and isolated clinicians hiding behind façades of confidence. This tendency leads to worse outcomes.
Benefits of intellectual humility
Although “I don’t know” gets harder to say, I am convinced it is one of the most important phrases in the practice of medicine. Embracing the intellectual humility necessary to utter those words has many benefits:
- Encouraging curiosity: this leads to broader differentials and more effective diagnosing
- Counterbalancing “intervention bias”: the tendency of clinicians to do something — anything! — when the best course of action might be to do nothing
- Effective teamwork: clinicians who admit they don’t know everything are more open to the input of others and more likely to see the patient’s big picture.
- Better education: A safe environment, where learners are empowered to disclose their gaps in knowledge, allows educators to address those gaps more effectively.
For newly minted resident physicians, my advice is to embrace “I don’t know.” You will do yourselves and your patients a great service. I will continue to say those three words as well, no matter how sharply it hurts my pride. If any of this inspires passion, positively or negatively, please leave a comment. I am looking forward to communicating with you this year through the Insights blog.