As a graduate student I once had a conversation with a friend who had gone to medical school. She said she was directly instructed to never say "I don't know." Whereas I was told by my advisor that another student had failed his qualifying exam because he never admitted when he didn't know, but tried to b.s. his way out of any answer he didn't know. I applaud your willingness to ask questions, and to try to slow down. Impatience and irritation lead to bad decisions in any area of life. Arrogance too.
I was on a fellowship interview not long ago and the program was discussing its "cultural humility"; when I asked what that meant, the answer I got was that it was a shift away from the notion of cultural competence to a sense that one should realize that they can never fully understand the cultural context of the patient (https://pubmed.ncbi.nlm.nih.gov/33424230/), and thus should cultivate a sense of humility instead.
This leaves me conflicted between some degree of agreement, but also a concern that this approach reifies divisions between people as irreconcilable.
I think humility can be used in many senses, some useful and others less so. The "cultural humility" stuff sounds more like a kind of fatalism, or as an excuse not to question the practices of certain people, although I can't be certain of that. Of course we can't "fully understand the cultural context of the patient"; we can't fully understand ourselves or our own cultural context or a lot of other things. But that doesn't necessarily imply irreconcilable differences that are clinically meaningful.
I think it is possible to remain both humble in the sense I described while recognizing that, while human difference is very real, we are in the end more alike than different.
I admire you writing this and appreciate it a tremendous amount. However, not everyone can handle uncertainty in a doctor. I've study some of the Stoic philosophies and read Meditations, but I have long understood that there is a reason that the old adage goes "practicing medicine". Doctors are human and don't know everything.
Unfortunately there are people that look to doctors and expect them to know everything and believe when a doctor tells them something, it is 100% fact. This was clearly apparent over the last few years.
I completely agree that doctors need to gain some humility, but the masses also need to understand that doctors don't know everything and most do the best they can.
Humility may be valuable but before endorsing it, studies need to be done comparing humility with confidence in taking care of patients. Absent that, the suggestion lacks scientific verification and might very well lead to patients not thoroughly trusting the physicians ability and therefore not following the recommended treatment plan.
I preface this comment with a time my family physician did admit he didn't know, excused himself, and looked it up. I don't think I've ever felt so sure and connected to a doctor since. Don't you think what a doctor thinks about him/herself and portrays to patients is due to the patients? It looks and sounds like a hamster wheel. "If I don't know, I won't be trusted". "If my doc doesn't know, I can't trust him". "If I admit frailty I'm vulnerable". "I wonder what grades my doc got in med school". "If I admit I don't know or I make a mistake I'll be sued". "If my doc doesn't get this right, my uncle the lawyer, will sue his butt". Is it because of the forever fear of pending lawsuits that doctors can't be open and honest? Are we as patients putting doctors into a position of no win - no win because he/she can never ever make a mistake with me, my mom, my son, etc? It's not like breaking a vase that can be replaced, there are times if a doctor makes a mistake it could be lethal. But that doesn't make him/her any less human than the rest of us. I get mistakes. I get not knowing. The case of RaDonda Vaught scared the pants off many in the medical field because we know it could be us at any given day, any time. We're all human but it doesn't mean we all behave with dignity.
I frequently tell patients I need to look something up and I can't think of a single time they reacted negatively. Even very psychotic patients, when I tell them I want to look something up to make sure I'm not making a mistake, will usually say something along the lines of "good idea doc".
My PCP is in her first year of practice. She googles right in front of me before writing prescriptions or ordering vaccines. I'm totally fine with that.
I remember, as class president in med school, I had to give the white coat ceremony speech prior to third-year rotations. I started it with these words: "So far in life, I have learned there are two incontrovertible truths: there is a God, and I am not Him." Not sure if I could say that today, because that would seem to indicate we are held accountable by Someone in an infinitely higher tax bracket. However, I can't help but wonder what would have happened if the large swath of public health officials, medical organizations, academic institutions, etc. possessed even a modicum of accountability and humility, admitting they were wrong on COVID-19 policies AND on all their critical theory epistemology. Their collective hubris is appalling and something akin to an Orwellian think tank.
I've worked with doctors for many decades, and whilst they are the full spectrum from charlatans to humble ministers, there is an unfortunate tendency for the true psychopaths to gain ascendancy - because they want power, and the ordinary physician does not.
At the head of many colleges, and in top government-facing roles, you may encounter some of the most disgusting human beings, who lack all responsibility and merely seek to dominate and humiliate others.
Thanks for a great article, I think arrogance an hubris has been the biggest problem over the last 3 years as far as most Doctors are concerned. This article reminded of a song by Chris Smither, some lyrics below.
The 2 lines that stand out are
Who's got all the answers if it isn't you?
No one's got them all though some will say they do.
Yeah, the wisest answer's one you learned a long time ago. I don't know.
I don't know.
Were you as big as you are now when I was born?
I've been this big a long time, that's why my face is worn.
Yes, but were you ever little, and if so where was I?
Yes I was but you weren't any where or any why.
How could I be nowhere if I'm here today?
Nothing is just nothing so who showed me the way?
And if something comes from nothing, then what makes it grow?
I don't know.
Who's got all the answers if it isn't you?
No one's got them all though some will say they do.
If they try to fool me, then what should I say?
You know if you're just polite they usually go away.
What's the dumbest question that ever there could be?
The only dumb ones are the ones that you don't ask of me.
And the wisest answer's one you learned a long time ago.
I don't know.
Yeah, the wisest answer's one you learned a long time ago.
I was a victim of MD arrogance as a young person without medical insurance. I waited the requisite 5 hr at Oakland Highland hospital county indigent care clinic only to be denied an x-ray. I knew I had a broken bone in my foot because of increasing pain. Limited swelling, so Dr knew best. Weeks later, I tried again, this time another Arrogant MD refused to X-ray the foot, he included degrading statements against my character in his report based on his speculation. A year later, with my foot 50% atrophied I was diagnosed with RSD, now called CRPS, a difficult disorder to treat and live with. I returned to clinic a year later to speak with Arrogant MD. I presented the X-ray and told her she denied me basic care and now have a challenging disease. I was 26 years old at the time. She just stared at me.
I did, no big payout. This was 30+ years ago, when most docs if they even heard of RSD considered it a mental disorder as opposed to neurological dysregulation problem.
I am sure you have learned a lot about RSD. It's not a mental disorder, but the psychosocial aspects (what you believe, how you feel, your experience as a human in the world to date) will most definitely affect your physiological responses to events that cause harm. And if that event is perceived as harm, like in your experience, the potential for RSD/CRPS is much greater. As a PT, every patient I had the experience of working with who had this diagnosis, was not seen or heard by the medical field and had a real harm event they were in the throes of. And RSD/CRPS was the end result. It makes me deeply sad for the person and angry at the providers for causing more harm on top of harm. I am sorry the medical field contributed to your pain experience. Ugh.
Thanks for the kind remarks. Yep, I have learned plenty about people, process, health and the medical institution. Again, the essay's sentiment, "when you don't know , admit it, and stop bluffing" speaks to my experience. I think the culture of the med schools encourage arrogance and the insurance directed protocols discourage analysis.
And then add the human mind that has trouble admitting it doesn't know. I had a patient yesterday ask me why something happened...I said I don't know and probably never will. He clapped his hands and said boy that's refreshing that you could be so honest. And I knew we were going to help this gentleman through whatever it was...even without knowing why enough to say why.
The best gift, my mentor ever gave me was the ability to say, “I really don’t know… But I bet together we can find out who does…“. It has been a gift to use ever since. It takes a lot of pressure off of being an “expert” - which by the way, the more expertise, I have the more I realize I have to learn. And that’s with everything in life.
What you said is right but we must consider that medicine is not math where one plus one equals one. On several situations the information from patients or about the illness is incomplete leading to mishaps or mistakes. The legal system and the public do not consider these situations and the implications put Physicians is the defense corner of denial.
As a graduate student I once had a conversation with a friend who had gone to medical school. She said she was directly instructed to never say "I don't know." Whereas I was told by my advisor that another student had failed his qualifying exam because he never admitted when he didn't know, but tried to b.s. his way out of any answer he didn't know. I applaud your willingness to ask questions, and to try to slow down. Impatience and irritation lead to bad decisions in any area of life. Arrogance too.
I was on a fellowship interview not long ago and the program was discussing its "cultural humility"; when I asked what that meant, the answer I got was that it was a shift away from the notion of cultural competence to a sense that one should realize that they can never fully understand the cultural context of the patient (https://pubmed.ncbi.nlm.nih.gov/33424230/), and thus should cultivate a sense of humility instead.
This leaves me conflicted between some degree of agreement, but also a concern that this approach reifies divisions between people as irreconcilable.
I think humility can be used in many senses, some useful and others less so. The "cultural humility" stuff sounds more like a kind of fatalism, or as an excuse not to question the practices of certain people, although I can't be certain of that. Of course we can't "fully understand the cultural context of the patient"; we can't fully understand ourselves or our own cultural context or a lot of other things. But that doesn't necessarily imply irreconcilable differences that are clinically meaningful.
I think it is possible to remain both humble in the sense I described while recognizing that, while human difference is very real, we are in the end more alike than different.
I admire you writing this and appreciate it a tremendous amount. However, not everyone can handle uncertainty in a doctor. I've study some of the Stoic philosophies and read Meditations, but I have long understood that there is a reason that the old adage goes "practicing medicine". Doctors are human and don't know everything.
Unfortunately there are people that look to doctors and expect them to know everything and believe when a doctor tells them something, it is 100% fact. This was clearly apparent over the last few years.
I completely agree that doctors need to gain some humility, but the masses also need to understand that doctors don't know everything and most do the best they can.
Humility may be valuable but before endorsing it, studies need to be done comparing humility with confidence in taking care of patients. Absent that, the suggestion lacks scientific verification and might very well lead to patients not thoroughly trusting the physicians ability and therefore not following the recommended treatment plan.
Thanks for sharing this. Humble acknowledgment of our own limits, as well as the limits of our tools, is critical.
Such humility is one display in this article on “curing” misinformation: https://journalofethics.ama-assn.org/article/science-and-ethics-curing-misinformation/2023-03
I preface this comment with a time my family physician did admit he didn't know, excused himself, and looked it up. I don't think I've ever felt so sure and connected to a doctor since. Don't you think what a doctor thinks about him/herself and portrays to patients is due to the patients? It looks and sounds like a hamster wheel. "If I don't know, I won't be trusted". "If my doc doesn't know, I can't trust him". "If I admit frailty I'm vulnerable". "I wonder what grades my doc got in med school". "If I admit I don't know or I make a mistake I'll be sued". "If my doc doesn't get this right, my uncle the lawyer, will sue his butt". Is it because of the forever fear of pending lawsuits that doctors can't be open and honest? Are we as patients putting doctors into a position of no win - no win because he/she can never ever make a mistake with me, my mom, my son, etc? It's not like breaking a vase that can be replaced, there are times if a doctor makes a mistake it could be lethal. But that doesn't make him/her any less human than the rest of us. I get mistakes. I get not knowing. The case of RaDonda Vaught scared the pants off many in the medical field because we know it could be us at any given day, any time. We're all human but it doesn't mean we all behave with dignity.
I frequently tell patients I need to look something up and I can't think of a single time they reacted negatively. Even very psychotic patients, when I tell them I want to look something up to make sure I'm not making a mistake, will usually say something along the lines of "good idea doc".
That's great. It certainly increases the trust patients have by seeing the openness, conscientiousness, humanness and honestly.
My PCP is in her first year of practice. She googles right in front of me before writing prescriptions or ordering vaccines. I'm totally fine with that.
I remember, as class president in med school, I had to give the white coat ceremony speech prior to third-year rotations. I started it with these words: "So far in life, I have learned there are two incontrovertible truths: there is a God, and I am not Him." Not sure if I could say that today, because that would seem to indicate we are held accountable by Someone in an infinitely higher tax bracket. However, I can't help but wonder what would have happened if the large swath of public health officials, medical organizations, academic institutions, etc. possessed even a modicum of accountability and humility, admitting they were wrong on COVID-19 policies AND on all their critical theory epistemology. Their collective hubris is appalling and something akin to an Orwellian think tank.
I've worked with doctors for many decades, and whilst they are the full spectrum from charlatans to humble ministers, there is an unfortunate tendency for the true psychopaths to gain ascendancy - because they want power, and the ordinary physician does not.
At the head of many colleges, and in top government-facing roles, you may encounter some of the most disgusting human beings, who lack all responsibility and merely seek to dominate and humiliate others.
Thanks for a great article, I think arrogance an hubris has been the biggest problem over the last 3 years as far as most Doctors are concerned. This article reminded of a song by Chris Smither, some lyrics below.
The 2 lines that stand out are
Who's got all the answers if it isn't you?
No one's got them all though some will say they do.
Yeah, the wisest answer's one you learned a long time ago. I don't know.
I don't know.
Were you as big as you are now when I was born?
I've been this big a long time, that's why my face is worn.
Yes, but were you ever little, and if so where was I?
Yes I was but you weren't any where or any why.
How could I be nowhere if I'm here today?
Nothing is just nothing so who showed me the way?
And if something comes from nothing, then what makes it grow?
I don't know.
Who's got all the answers if it isn't you?
No one's got them all though some will say they do.
If they try to fool me, then what should I say?
You know if you're just polite they usually go away.
What's the dumbest question that ever there could be?
The only dumb ones are the ones that you don't ask of me.
And the wisest answer's one you learned a long time ago.
I don't know.
Yeah, the wisest answer's one you learned a long time ago.
I don't know.
I was a victim of MD arrogance as a young person without medical insurance. I waited the requisite 5 hr at Oakland Highland hospital county indigent care clinic only to be denied an x-ray. I knew I had a broken bone in my foot because of increasing pain. Limited swelling, so Dr knew best. Weeks later, I tried again, this time another Arrogant MD refused to X-ray the foot, he included degrading statements against my character in his report based on his speculation. A year later, with my foot 50% atrophied I was diagnosed with RSD, now called CRPS, a difficult disorder to treat and live with. I returned to clinic a year later to speak with Arrogant MD. I presented the X-ray and told her she denied me basic care and now have a challenging disease. I was 26 years old at the time. She just stared at me.
sue, obviously
I did, no big payout. This was 30+ years ago, when most docs if they even heard of RSD considered it a mental disorder as opposed to neurological dysregulation problem.
I am sure you have learned a lot about RSD. It's not a mental disorder, but the psychosocial aspects (what you believe, how you feel, your experience as a human in the world to date) will most definitely affect your physiological responses to events that cause harm. And if that event is perceived as harm, like in your experience, the potential for RSD/CRPS is much greater. As a PT, every patient I had the experience of working with who had this diagnosis, was not seen or heard by the medical field and had a real harm event they were in the throes of. And RSD/CRPS was the end result. It makes me deeply sad for the person and angry at the providers for causing more harm on top of harm. I am sorry the medical field contributed to your pain experience. Ugh.
Thanks for the kind remarks. Yep, I have learned plenty about people, process, health and the medical institution. Again, the essay's sentiment, "when you don't know , admit it, and stop bluffing" speaks to my experience. I think the culture of the med schools encourage arrogance and the insurance directed protocols discourage analysis.
And then add the human mind that has trouble admitting it doesn't know. I had a patient yesterday ask me why something happened...I said I don't know and probably never will. He clapped his hands and said boy that's refreshing that you could be so honest. And I knew we were going to help this gentleman through whatever it was...even without knowing why enough to say why.
The best gift, my mentor ever gave me was the ability to say, “I really don’t know… But I bet together we can find out who does…“. It has been a gift to use ever since. It takes a lot of pressure off of being an “expert” - which by the way, the more expertise, I have the more I realize I have to learn. And that’s with everything in life.
" Congress is terrible but think their own congressman is doing a fine job. "
LOL. Definitely our state's Senators *are* the problem. Maybe the rest of yours are actually ok.
If doctors are serious about regaining trust, they need believable performance metrics. The reference to Magnus Carlsen was spot on.
Sorry 1 + 1 = 2!!
What you said is right but we must consider that medicine is not math where one plus one equals one. On several situations the information from patients or about the illness is incomplete leading to mishaps or mistakes. The legal system and the public do not consider these situations and the implications put Physicians is the defense corner of denial.
GREAT ARTICLE! As others have already mentioned, this approach really applies to us all.