Tuesday, June 10, 2008

Medical Truths #2

The most important sentence a doctor can speak is "I don't know."

Our medical schools are chock full of high performers (gunners, in parlance), being taught that the right answer is imperative. Differential diagnoses are screened a-la-House, M.D. and the message is to always be right, and always have an answer. I remember students being berated for "guessing with your mouth open," a favorite phrase, of one particular attending. That mindset is reinforced all through training. Primary care doctors are told to be gatekeepers, and that they should have the ability to treat everything. Certain insurance structures (such as capitation) financially punish those doctors who refer out to specialists or order to many tests. And doctors are given a heavy responsibility (patients' health), for which they do not want to be wrong, and thus be a failure.

It's good to know stuff. We want our students and residents to learn by experience and going to find information that will help in the diagnosis. Certainly we all want to have confidence in our physicians. And there are many benefits in gatekeeper medicine. (Having one doctor keeping track of all of a patient's treatments is one.) Illness, though is not so black and white. However, there is very little positive reinforcement for the student or resident when presented with these grey areas, and even less for those in practice.

Patients respect an "I don't know," even though it may be frustrating to hear it. Most do not expect doctors to be superhuman. I recently had a friend of mine (another physician) be told that he had stage 4 cancer by a national expert, only to find that his nodules in his lungs began to shrink with antibiotics were given by another doctor who said "I don't know." He's glad that the doctor didn't.


Alan said...

Just found my way over here from Geoffrey's blog. Interesting stuff. :) Did you see the list in Wired "Top 5 Reasons to Dislike Premed Students?" It was amusing.

Here was my (mostly) tongue in cheek response:



Geoffrey Kruse-Safford said...

I have never heard it, and while I couldn't agree more, I have enough second and third-hand experience with people's frustrations with medical ignorance to believe that part of the problem lies with patients' expectations. For the most part, we want answers, and we want them now.

This is not to excuse doctors from needing to be honest enough to say, "I don't know". I think it important that the words that follow that admission continue to be honest - that a search will continue until an answer is found, etc., etc.

Doc said...

Thanks for visiting, don't be a stranger. I had read Wired's article, and agree with some of the sweeping generalizations as having kernels of truth. As you cheekily retorted, these qualities are not unique to Pre-Med students--some of them do take their need to be the best (and always right) to the extreme.

One of the great eye-openers in my life was the realization that the back-biting, cliques, and narcissistic attitudes which I observed in high school and college were worse among these "best and brightest." There are some med students who believe it is their birthright to be physicians. There is hope: I know that the schools are now trying to have a greater variety in the selection process, I believe, in part to try to bring better balance to the programs.

Absolutely right. "I don't know" followed by "Pay the secretary on your way out," is just plain wrong. Doctors should be well informed, and should always be willing to go and find answers or do whatever it takes to best serve the patient.
Ignorant or lazy doctors, dangerous as they may be, will usually be identified and avoided over time. But a doctor who is unwilling to say these three words is the most dangerous of all in my book.

BTW, Alan, we used to say in residency that idiopathic meant that the patient is pathologic, and the doctor is an idiot. Although if you translate the root words, it sounds like Homer Simpson: "Stupid Disease."

Alan said...

"Although if you translate the root words, it sounds like Homer Simpson: "Stupid Disease.""

DOH! :)