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Teaching and Learning Moments

The “I Don’t Know” Moment

Frush, Benjamin W. MD, MA

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doi: 10.1097/ACM.0000000000003762
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“What should we do?” Mike, an intern on the team, asks as he looks toward me expectantly. It is my first week as a supervising resident, and I realize that this is the moment I have been dreading since my intern year ended. The patient in question is a medically complex gentleman admitted for transient hypothermia, and we are deciding whether a full sepsis workup is indicated.

This is an unprecedented clinical scenario for me. I lack a trusty illness script or diagnostic schema to draw upon. A quick perusal of UpToDate offers little guidance. So now I am faced with dual dilemmas; not only with what to do for this patient, but also with how to display (or obscure) this gap in my medical knowledge to Mike.

I have come to view this first “I don’t know” moment as a senior resident as seminal for the medical trainee; as formative as it is ubiquitous. While there is little opportunity to hide our ignorance as interns, the temptation to do so when asked by those supposedly lower on the totem pole is strong. Such feigning may not always be overt; it may be as subtle as surreptitiously texting our resident friends for advice or stepping out of the room to call an attending—anything to maintain the façade that we have it together.

And yet, might the desire to maintain that façade be our undoing as fledgling clinicians in 2020?

In an erstwhile era, perhaps the virtue of intelligence was the sine qua non of good doctoring, and the possession of a capacious memory its necessary precondition. In such a setting, the ability to recall important information in a time-sensitive fashion was critical, as the alternative would be lumbering over to a physical library to sift through textbooks or medical journals.

Yet today, the virtue of humility seems far more important, manifested in the ability to ask for help. While a solid knowledge foundation is critical, the ability to access and summon vast sums of medical information with the click of a mouse or the swipe of a thumb renders an Oslerian memory of medical esoterica less important. Indeed, the sheer amount of medical information has increased exponentially over the past several years, to the point where it is now in fact impossible to truly know it all.1 Far more important then, is possessing the resourcefulness to know whom to ask, and the courage to do so openly.

Unfortunately, as medical trainees, our ability to seek help publicly is hampered by decades of academic competition, which causes us to view knowledge as a zero-sum game. The dreaded bell curve of the Medical College Admission Test and the United States Medical Licensing Examination Step 1 means I can only be successful at the relative expense of others. Compounding our competitive nature is a deeply entrenched culture of shame that still permeates medical education and practice, even as we recognize its destructive effects on learning.2,3 In residency, the transition to viewing knowledge as a common good, pursued collectively for the benefit of our patients, is hard earned.

It took me a few minutes to muster those 3 dreaded words—“I don’t know”—to Mike. Yet afterward, it felt like a weight had been lifted. We called our attending and together agreed upon a plan that proved successful for our patient. Before hanging up, she thanked me for asking for her help. I thanked Mike for asking for mine, who in turn thanked me for calling our attending.

Such is the power and joy of mutual humility in medicine; to transform a jealous knowledge into the sharing and receiving of gifts.

References

1. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48–58.
2. Bynum WE 4th, Adams AV, Edelman CE, Uijtdehaage S, Artino AR Jr, Fox JW. Addressing the elephant in the room: A shame resilience seminar for medical students. Acad Med. 2019;94:1132–1136.
3. Case GA, Pippitt KA, Lewis BR. Shame. Perspect Med Educ. 2018;7(suppl 1):12–15.
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