5 hours ago
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I have always thought, and still tell prospective medical students, that the most attractive part of being a doctor is there is something in it for everyone who has a thirst for knowledge.
From the quiet thinker to the gregarious soul, detail-driven to big-picture person, staunch researcher to unabashed clinician, most of us will find a home in medicine, even if, in a sorry postscript, a fraction of doctors will become disillusioned and even leave for reasons that are all too familiar.
Knowledge in medicine has come a long way.
The HIV ward, the scene of graphically ill patients when I was training, is long closed because it’s no longer needed in most rich countries. When my young neighbour had a stroke, doctors cleverly retrieved the clot suffocating his artery, not just saving his life but also returning it to its full potential. An acquaintance just donated a kidney to a sibling, allowing two lives to continue nearly as they were before.
In my own field of oncology, there used to be very few successful therapies. Palliative care was in its infancy in the minds of many, including doctors. A societal expectation that patients deserved more say in their care was still taking shape, and doctors wielded a lot of power, both in the corridors of the hospital and the lives of patients.
Today, that whole landscape looks unrecognisable.
Despite all that knowledge, my first year as a qualified oncologist missed the mark. I think so did a few of the ensuing years. To be clear, I had a handle on many facts. I knew how to prescribe chemotherapy (after all, the sum of our knowledge was contained in a handbook), could interpret results and capably attend sick patients. What I didn’t know was how to answer their more searching questions.
Medical journals depicted survival curves, but the recently separated father wanted to know where he sat on the curve so he could figure out how to spend his time with the kids. A matriarch asked if the median survival for her illness was 12 months whether she would “definitely” live to see the grandchild due in half that time. If a drug had a less than 5% response rate but a near-universal risk of causing severe harm, should a single parent take a chance on it?
The glum and silent answer in my head to such questions was, “I don’t know.”
But that wasn’t all.
When a “mixed response” meant that some tumours were getting larger and others smaller, should one portray the glass as half empty or half full? When patients asked how other people fared on chemotherapy, how best to convey that this had little bearing on an individual’s experience? As I stamped my newly gained credentials on the notes I wrote, I envied the self-assurance of my colleagues. Maybe I was all stamp and no substance.
It increasingly struck me that the words and actions of an oncologist can be greatly consequential and even life-altering for many people – such as telling patients they are unlikely to be alive for a primary school graduation, or that the only way to attend a wedding is for the wedding to be held now.
For me, getting this bit of medicine right was the most tempting and the most taxing.
We could use data to make well-educated guesses but there was no denying the element of uncertainty and indeed, having the courage and tact to share it with the patient. But a good oncologist also had to gain trust – and for that, one must project confidence. Imagine having a serious illness and a doctor mostly mumbling, “I don’t know.” What’s even more problematic, though, is when doctors are sure without being right.
The human body is humbling – patients with aggressive disease defy predictions and those handed an excellent prognosis return with disease. Still, I had the illusion that one day I would know so much that I’d rarely need to say, “I don’t know.” Twenty-five years in, I find myself saying this more, not less. The more I see the less I am “totally sure” about.
But here’s the thing: far from losing faith or questioning what kind of “proper” doctor would admit this, patients seem to appreciate the vulnerability.
Because “I don’t know” is not defeatist if it is followed by, “But I am going to stay the course with you and be open and honest about what I do know and can find out.”
As students and trainees, we are taught that to acknowledge our limitations is to do right by the patient. When we qualify, we must pretend to have all the answers. A more useful approach would be to scrap this mirage.
It is true that sometimes our colleagues will fill in the gaps with their technical prowess or superior knowledge: technology and multidisciplinary input have made this a lot easier. But there will be many times when we must fill in the gap ourselves: there is no substitute for self-awareness and honest conversation.
Like many doctors, I used to think I was alone in my feelings of inadequacy; it took me a long time to work out that this is a silent affliction.
So when I read this thoughtful essay from a freshly minted radiation oncologist, I was glad that someone had figured out earlier than me that “I don’t know” does not mean “I have nothing to offer”.
If medicine taught this more explicitly from the outset, our patients would be better served.
