Being Able To Admit Ignorance

It’s human nature to seek definitive answers, especially when dealing with one’s own health.  It’s not uncommon for me to see patients whose symptoms aren’t particularly bothersome but which have gone on long enough that anxious curiosity compels him or her to seek medical care.  When we get sick we want to know what the illness is, both for our peace of mind and in order to be able to explain ourselves to others.  We know that a diagnosis is the first step toward fixing the problem.

As much as we yearn to have answers for ourselves I would submit that it is even more ingrained in doctors to want to provide answers for their patients.  This is the reason, I believe, that doctors find it so difficult to utter these three words: I don’t know.  It should actually be pretty simple—we come across situations every day where we can confess ignorance without straining every neuron in our brains.  Daddy, why is the sky blue?  I don’t know.  Honey, how is it possible you forgot our anniversary again this year?  I don’t know.  Can you please explain to the court what possessed you to drive 80 mph in a 35 mph zone?  My client pleads ignorant.

When it comes to patient care, however, that part of the brain that is responsible for expressing a lack of knowledge began its long decline into atrophy the day we entered medical school.  Blame it on all the tests, if you’d like.  By the time a fully-trained specialist sets her number-2 pencil down at the end of a board certification exam she has taken hundreds of tests, both short and long, that comprise exactly 184,312 questions (okay, so I made that number up—as I said, it’s easier to invent answers than admit not knowing).  Most questions are multiple choice, some are true/false, a few are essay type, but they all have one indisputable characteristic in common: there is a correct answer to each.

What I’m saying is that thousands upon thousands of test questions have trained us not only to find the correct answer but to also expect that such an answer exists.  In all the examinations we take you won’t find a single one with the following choices: A) systemic lupus erythematosis, B) polycythemia vera, C) bullous pemphigoid, D) the correct diagnosis cannot be known based on the information provided.  No, we don’t get to answer “I don’t know” and expect any outcome other than an invitation to try a new career that doesn’t involve a direct knowledge of science.

An even more compelling reason for being unable to admit ignorance is our deep desire to help people.  People who are suffering and anxious come to us for relief, and because of this we have a strong urge to provide a reason for their misery.  There’s nothing more deflating than to conclude a patient visit with “I’m sorry Mrs. Smith, I just don’t have a clue what’s going on with you.”

To make matters worse, that small crevice in our craniums that used to house the I-don’t-know function has now become filled with a new structure, the so-called “let’s-just-try-another-prescription” lobe.  Even though we haven’t the faintest notion what the problem is we nonetheless figure that one more medication might just do the trick.  It’s this mentality that got us into trouble with drug-resistant bacteria—for so many years now we’ve treated so many ailments with antibiotics that we’ve cultivated a whole new batch of nasty bugs that don’t respond to even our most potent agents.  Not only that, but we’ve also led generations of patients to believe that unless every sniffle and sneeze gets a ten-day course of Gorillacillin the patient will drift into a septic coma from which they’ll never recover.

A good example of the medical community reaching too far for a diagnosis is found in the annals of cardiology.  A few decades ago our country saw such a rise in the number of patients diagnosed with mitral valve prolapse (MVP) that it almost looked like an epidemic.  MVP is a legitimate entity where the cellular architecture of one of the heart valves is less rigid than it should be and allows the valve to flop back into the atrium instead of firmly slamming shut.  In a small minority of patients who have considerable valve leakage surgery is needed—in all others MVP tends to be a clinical nonentity, a benign diagnosis that requires no therapy.  In the 1970s and 1980s, however, thousands of patients—mostly young or middle-aged women—were saddled with the diagnosis of MVP whenever they presented with any of a number of vague symptoms: chest pain, fatigue, anxiety, palpitations, depression.  It was the go-to diagnosis for anyone wanting to placate an anxious yet healthy young woman by assigning a medical syndrome.  The truth, as we’ve learned now that we have improved echocardiographic imaging, is that about 90% of the people who were diagnosed with MVP actually have normal mitral valves.  The real disease didn’t rest with the patients—the real abnormality resided with the cardiology community that hoisted onto healthy patients a clinical label rather than simply admitting “I don’t know.”

I think we as doctors forget one fundamental fact about this whole issue.  By saying “I don’t know” we’re not giving up, or admitting defeat, or failing the patient who has put their trust in us.  When you do a thorough evaluation and come to the conclusion that you don’t know the answer, the phrase “I don’t know” means far more than it appears on the surface.  A good clinician declaring ignorance is really saying much more: I may not know what is causing your symptoms, but I’ve done a thorough investigation into your case and can conclusively say that you don’t have any of the truly dangerous medical problems that can produce symptoms similar to yours.  So while you may come away from our visit without a knowledge of what is causing your problems, at least you know what it isn’t, and you can rest assured that we have looked for—and excluded the possibility of—anything that puts your life or health at significant risk.

Such an admission is bound to be worth much more to a patient than simply taking a stab in the dark at a catch-all diagnosis.  By avoiding applying an incorrect label you are allowing the patient to feel comfortable searching for a diagnosis elsewhere—bear in mind that a patient who comes away without a firm diagnosis in your area of specialty is now free to look elsewhere and may just come across a doctor in another field who is in a better position to correctly identify the root of the problem.

In the end, we humans are complicated creatures who frequently suffer from bizarre, often transient problems that can be vexing, painful, annoying, and miserable, but which are not readily categorized by modern medicine into clinical syndromes as cleanly demarcated as what we find in our textbooks.  Admitting “I don’t know” may go against all the wiring in our heads, but as doctors sometimes it’s the most useful diagnosis of all.