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 a TP53 mutation.”

Internist: “I have no idea what that means. Can you explain it to me?”

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 marked by the absurd volume of information I was learning and the freedom to admit I knew nothing. I am sure these two facts were related. Because expectations 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 could 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.” A good question was one the higher-ups were happy (and able) to answer. I caught on pretty quickly, 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. Attendings and program leadership mostly expected me to show up and do what I was told efficiently. Internship was even better than the start of medical school because I was protected from questioning. Pimping was aimed at the medical students — 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” 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 to be careful. I didn’t want my peers, the program director, or department chairman — it was an era that the chair came to most reports — 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 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 attendings’ 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 when 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 to 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 was made to feel small and forced to endure an unwanted lecture.

These episodes were unpleasant, but they taught me a couple of things about mentoring:

1. Value the people who trust and respect you enough to seek your counsel; it makes it easier for them to learn.

2. Figure out what they are asking and what the learner knows 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 not interested in).

As an attending, I learned how to look smart. Over-preparing for everything, no matter how unimportant the activity, makes you look smarter than you and 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 for a one-line recap of 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 that my ability to quote the medical literature on every subject would serve as a future goal. He hadn't noticed that I could quote the medical literature only on subjects I steered the conversation 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: years of practice, promotions, accomplishments, and accolades. 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 have written about my “CV of failures”. I describe to consultants exactly what stumps me about cases. 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 explain why. 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 offer only the briefest moment when 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? 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 respect must be earned, but disrespect is not the default? And how can we instill greater confidence and security in our learners and doctors from the earliest stages?

Photo by David Tyemnyak on Unsplash