Friday Reflection #21: Revealing Ignorance
CB is a 72-year-old woman with macrocytosis and otherwise normal cell counts. After an unrevealing evaluation, her internist referred her to a hematologist.
Hematologist: “You won’t believe this, CB, the patient you referred to me, she has megakaryocytic dysplasia with 5q and 12p deletions and the TP53 mutation.”
Internist: “I have no idea what that means, can you explain it to me?”
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When I started medical school I knew remarkably little medicine, even less than the rest of my generally uninformed peers. Early in my first semester, I was talking to my roommate from college (who was doing an actual job at the time) when he asked what I was studying. I told him we were dissecting the perineum in anatomy. I had never heard the word “perineum” before and thought he’d be impressed and ask me about it. I was surprised that he knew exactly what I was talking about.
These first days of medical school were notable for the absurd volume of information I was learning and for the utter freedom I had to admit that I knew nothing. I am sure these two facts were related. Because the expectations of us were low, we were not judged on what we already knew. A student’s baseline knowledge of the brachial plexus provided no benefit beyond the first five minutes of a lecture. We were free to ask any question.
This privilege did not last. When I began my clinical rotations, it was clear that auditions had begun. We were quizzed (pimped in the parlance of the time) relentlessly. While I wasn’t really expected to know anything about neurosurgery on the first day of my elective – that is why I was taking the elective – I was judged by what I already knew. The game was to appear smart, able to answer many of the questions posed, but also able to ask the questions that your resident and attending thought were “good questions.” The definition of a good question was one that the higher ups were happy (and able) to answer. I caught on pretty quick, and because I actively hid my ignorance, I got excellent grades and learned less than I could have.
Internship brought a bit of a reprieve from the “I know nothing but can’t admit it and I can’t learn if I don’t admit it” conundrum. Nobody expects an intern to know anything. I was mostly expected to be ever-present and efficient at doing what I was told. Internship was even better than the start of medical school because I was protected from questioning. Pimping was aimed at the medical students because it was acknowledged that interns were worker bees and too tired to be reading. I only opened my mouth if the student had given up and I was awake and knew the answer.
Becoming a resident, not knowing once again became unacceptable. I was supposed to be “The Fat Man”[i] the all-knowing doctor who could teach medical students, guide interns, run interference with attendings, and provide medical care to patients. Residency did provide safe spaces for learning. “Resident report” was a place you could relax, let your guard down, reveal knowledge gaps, and learn. But even here, I felt I needed be careful. I didn’t want my peers, the program director, or department chairman to think less of me.
During residency I learned how I could learn without revealing knowledge gaps. I listened closely to everything my peers and attendings said on rounds and eavesdropped on any conversation that seemed like it might be useful. I also constantly questioned pharmacists, translators, physical therapists, nurses, and the hospital chaplains. These were people happy to share their expertise and who seemed to think more, rather than less, of me for asking questions.
And then I was an attending. For the first time, I was actually, truly, supposed to know things. I was the new guy who needed to prove himself to colleagues, residents (known for sniffing out attending’s weaknesses), and students. Oh, and patients, who can present you with any concern and expect you to be ready with a diagnosis and management plan. We all say we want a doctor who can admit when he doesn’t know something. What we really want is a doctor who knows his stuff but can admit when he doesn’t know something on the rare occasion he doesn’t. This was the point in my career at which the imposter syndrome was most acute. I felt I had finally reached that point where I would be found out.
Like with resident report, there are always places where one can admit ignorance and get guidance. As an attending, these were people more than places, colleagues who thought enough of me that their opinion would not turn with a few stupid questions. These were mostly people just a little bit senior to me; people I liked, respected, and trusted.
For each of these people, there were the opposites. The people I didn’t know but was forced to consult, people who assumed I knew nothing. These interactions were memorable. I would ask a question and, whether or not I got the answer I needed, I definitely was made to feel small, made to suffer a ‘splaining.’[ii]
These episodes were unpleasant, but they taught me a couple of things about mentoring. First, valuing those who trust and respect you enough to seek your consultation makes it easier for them to learn. Second, figure out what the questioner knows and what they are asking before you start to teach. There are few things more insulting for a learner and less efficient for a teacher than to teach someone what they already know or are uninterested in.
As an attending, I also learned how to look smart. Over preparing for everything, no matter how unimportant the activity, not only makes you look smarter than you are but actually makes you a better teacher and doctor. I learned to spend extra time preparing for clinic sessions. I was taught to ask my resident to call me at night to give a one-line recap on each admission. These calls made it seem like I was helping out: giving pointers, suggestions, and words of encouragement (as well as finding out how everyone took their coffee on morning rounds). But mostly, these calls gave me a head start. Neurosarcoid? Yikes, I’ve forgotten everything about that. Better spend some time with Harrison’s or UpToDate before bed.
I also mastered the ability to shift every conversation to something I knew well, often a topic I had recently prepared a talk on. I remember getting feedback from one resident who seemed honestly impressed with my breadth of knowledge. He told me he would use my ability to quote the medical literature on every subject as a model to emulate. He missed the detail that I was able to quote the medical literature on every subject I had steered the conversations toward. During that month, I had quoted from every single article I knew. Had I ever worked with him again he would have found me out.
In the last few years I have arrived at a place in my career where I’ve become completely unconcerned about other people’s assessment of my knowledge. I can only guess at the cause of this transition: the accumulation of years of practice, promotions, accomplishments, and accolades.[iii] My present mindset is: “I know a lot about a lot of things. There is even more I don’t know. If you don’t respect me for what I do know, I don’t really care.”
I now seem unable to keep quiet about what I don’t know. I spent one afternoon crafting a “CV of failures.” I have spoken (three times) at a session for the medical students titled, “Pritzker, I Screwed Up.” I describe to consultants exactly what it is about cases that has me stumped. To the aggravation of a student or two, I butt in when a colleague is teaching about something that I think I can learn from.
This approach is obviously superior to my previous tendency to hide my weaknesses, so much so that it seems absurd to even state the reasons. Denying the fact that there is much I don’t know hurts nobody but me and my patients.
As in any career, one enters medicine knowing little. Medicine, however, seems to provide only the briefest moment in which it is acceptable to admit ignorance. Why did it take years for me to reach a time in my career when I am comfortable admitting my knowledge gaps, a time both pleasant and productive?[iv] How can medical education be retooled so there are more spaces for honest and open questioning, places and times when people are coached and not judged? How can workplaces be organized so that respect needs to be earned but where disrespect is not the default? And, how can we figure out a way to instill greater confidence and security in our learners and doctors from the earliest stages?
[i] Having now referenced “House of God” in two Friday Reflections, I might need to make a third attempt at reading it.
[ii] I go with ‘splain as the verb, rather than mansplain, because: A. I am a man and B. two of the four worst ‘splaining episodes of my career were courtesy of women.
[iii] There were two other things that I think I can attribute the change to that I am not quite shameless enough to admit here.
[iv] I do recognize that I am privileged to be allowed this honesty. There are many people who never garner the respect or attain the self-confidence and job security to reach this stage.