Back in 1956, after completing my first year in a rotating internship, I had a few months off before reporting for duty in the US Army. I spent six weeks of that time covering a busy, primary care practice.
As the doc headed for the door, he stopped long enough to advise me on two points. First, he said, “One, all you need for record-keeping is a few 6 x 8 cards. Onto those cards you can write the patient’s whole story. Two, NEVER let the patient know that you don’t know something.”
The second bit of advice helped me become a better physician because, during those six weeks, I felt like an imposter. How could I relate to the patient and family if I had to cover constantly my eternal ignorance with the façade of acting like the all-knowing physician?
Thereafter, I swore that I would always level with the patient and family about the limits of my understanding of an illness.
From that time to my retirement, over six decades later, I frequently told patients the things that I did not know. And, in front of the patient, I made it a habit to seek out as much information as possible, even to the point of consulting Dr. Google! I found that my admission of ignorance had positive results. It engendered trust.
Some patients, of course, did feel uncomfortable with my uncertainty, and my secret desire was that they would seek care elsewhere. By this point, I owned my ignorance and uncertainty and refused to relinquish it to the veneer of an all-knowing bedside manner.
Over the years, I found terminal illness to be particularly rife with uncertainty in terms of predicting when death would occur. When discussing prognosis, I found it helpful to understand the narrative, the story of the patient and family, in the context of the relational, social, legal, economic, cultural and religious aspects.
To that end then I would usually suggest that the patient might die sooner than at a later time. I found this approach more respectful of the patient and family. It allowed everyone to share in the uncertainties and created an environment in which all the loved ones could better particulate in the patient’s lasts days.
Instead of doing as instructed by my mentor in 1956, I have learned to follow the more recent advice of a program at the University of Arizona Medical School. According to the “Curriculum on Medical Ignorance,” there are at least four ways we manage our ignorance and uncertainty: (1) I know that I know; (2) I don’t know that I know; (3) I know that I don’t know; and (4) I don’t know that I don’t know. They say that the last may be the most dangerous of all. And I heartily agree!
Madison, New Jersey