Hey everyone, it’s Medicine Mondays again. Today I’m going to talk about a pretty simple concept: “Knowing What You Don’t Know”.

Knowing What You Don’t Know?

Yea, but before we go there, let’s look at a more basic and easy to understand concept which is: Knowing What You Know

Knowing What You Know is simply having the knowledge about something and having the confidence to apply that knowledge. For a physician, some of it is knowledge and some of it is experience.

When you ask an ER doctor to see a patient who has the classic presentation of acute cholecystitis, they know what to do. They do a lot of things at the same time and quickly, because they just know what to do. Off the top of my head, they’ll examine the patient, check for Murphy’s sign, decide whether to get a confirmatory Right Upper Quadrant Ultrasound, or if there is concern it may be something else, maybe they’ll get a CT of the Abdomen and Pelvis first. Sometimes you may need to confirm with a HIDA scan, which is the most sensitive test, although not as commonly used in an emergency setting.

Once the diagnosis is confirmed, the ER doc lets the surgeon know. They confirm the findings and look at the imaging to make sure they agree. Then depending on the patient situation, time horizon, and complexity of the case, they may opt to do the surgery the next day or emergently. In other cases, they may want to ask Interventional Radiology to place a cholecystostomy tube or other drainage catheter.

Basically, the whole point is that in this situation, the each doctor knows what to do. So, Knowing What You Know is pretty easy, it all comes down to knowledge, confidence, and experience with the situation.

I see… so?

So then, the next concept is “You Don’t Know What You Don’t Know”.

At its core, this is essentially a hole in a person’s knowledge and experience base. However, this hole is so large, that they don’t know it exists.

It’s difficult to explain, but I’ll try.

There is another saying, “When you’re a hammer, everything is a nail.” This saying has to do with when your scope is too narrow, you try to fit everything you see into a compartment that you know (and are confident in).

So, for example, if you’re a hammer and you think everything is a nail, that’s fine for the most part because there are probably a lot of nails around. However, once in awhile you’re going to encounter a screw, and you’re going to think it’s a nail. In this case, your hammer just won’t work because you need to be a screwdriver — something you don’t know how to be.

So what can we do about “You Don’t Know What You Don’t Know”?

The most important thing is to simply be aware of it, which brings me to the original concept:

Knowing What You Don’t Know

I think this concept is the most important, and also the most uncomfortable.

Medicine is expansive which is why we have so many different specialties and subspecialties. You can’t possibly know it all. Forget zebras, there are even unicorns that exist in the medical field.

Coming to terms with this fact is kind of like a form of medical enlightenment. You are comfortable in the knowledge you do have, but also aware of your own weaknesses. It’s ok to ask for help. That said, everytime you gain knowledge/experience of something you didn’t know before, that doesn’t immediately place it into the “Knowing What You Know” category.

I think the best way to illustrate this is from Dr. Cox and Scrubs:

Some background may be in order. In Scrubs, Dr. Cox is kind of who JD and the others look up to, although he tends to be “mean” to them, he genuinely cares about teaching him.

However, even Dr. Cox has a chink in his armor, metabolic diseases. What is interesting about this particular scene (and episode My Catalyst) is that Dr. Cox is aware of his own weakness.

Then at the end of this arc, there is another scene with Dr. Kevin Casey, who is considered almost like a god-like existence to both the Medicine (JD) and Surgery (Turk) teams, can’t stop washing his hands, since he suffers from OCD.

“This a weak moment. No one’s ever supposed to see this.”

“Everyone’s got their own burdens JD. I’m not gonna be one of those people that dumps mine on someone else.”

Scrubs was a great show because it shows how human doctors are.

I went a little off topic here, but it was to illustrate a point. You want the ability of “Knowing What You Don’t Know”. It’s a little bit scary at first because you have to come to terms with what you may consider to be a “weakness”. However, you will gain a lot more knowledge and experience from this enlightenment.

TL;DR

Knowing What You Don’t Know is something I think is important for young doctors to understand early in their careers.

You Don’t Know What You Don’t Know is something you should always keep in the back of your mind.

Knowing What You Know is important, and you should share this knowledge with others.

Scrubs is a great show, I should rewatch it again.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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