Telling A Patient "I Don't Know" Takes Years of Practice.

Telling A Patient "I Don't Know" Takes Years of Practice.

by The Happy Hospitalist

Physicians don't know everything. You may or may not have been raised to believe that physicians will always have the answers to all your questions.  They don't.  Not even the subspecialists whom patients believe are supposed to know everything. They don't. 

For many physicians, one of the hardest things to learn is how to tell the patient "I don't know". Medical school and residency offers no curriculum  that teaches your doctor how to tell you "I don't know".  For many doctors, admitting failure to the patient is a form of torture.

Telling patients "I don't know" takes practice.   Actually, it takes a lot of practice. You wouldn't think so, but for many new physicians, admitting their lack of knowledge about the science of your disease process is not easy.

I remember how hard it was to get through complete history and physical examinations during my early years as a third year medical student and then having to tell the patient I didn't know what was going on.  Telling a patient you don't know is hard.  Some doctors will never get comfortable with saying it.

As a resident, physicians are expected to engage in a greater sense involvement with their patient's care plan.  They are also expected to know more and more as the years progress. But rarely does one show up in morning report with the right answer being "I don't know".  Not knowing is never an acceptable answer during the grueling physician training process.  And many physicians train to accept that as the truth once they leave their academic training centers and enter the real world. 

I remember fielding hundreds of "That's the first time anyone has ever asked me that" type questions in my resident clinic.  I always seemed to have an answer  even if it wasn't the right answer.  I remember how hard it was to sit there, face to face, with a patient asking what may or may not have seemed at the time to be simple, easy and straight forward questions.   I remember thinking to myself that I should know this, but I don't. 

After seven years as a hospitalist and thousands of patients later, I find telling patients "I don't know" to be one of the easiest parts of my job as a physician.  If I don't know an answer, I don't hesitate.  I just tell the patient up front that I don't know.  And when I don't have an answer, often times the reason is because there is no answer, at least not the answer the patient is looking for.  In my clinical practice one of the most common indications I have found for telling patients "I don't know" comes in patients with chronic pain of unexplainable etiology that only responds to that drug that starts with a D.

Happy:  Ma'am, I understand you're having 12/10 abdominal pain,  I have concerns about pursuing further evaluation given the dangers of CT scan radiation exposure we are learning more and more about every day.  I think I am comforted by the fact you have had twelve CT scans, four ultrasounds, an exploratory surgery and hundreds of esoteric labs drawn in the last year,  all of which have been normal.  I am also comforted by your ability to keep down the Big Mac your boyfriend brought you an hour ago.  I see you have previously been referred to the outpatient pain clinic but refused to take the Elavil they recommended.  I have  previously discussed my concerns with you regarding your body's evidence of tolerance and dependence to narcotics, but you declined further evalutaion of this care modality.  I don't know why you're having abdominal pain for the last three years that only responds to dilaudid, but I have nothing further to offer you in your hospital care. I'm going to discharge you to home today.

Patient:  I can't go.  I'm having too much pain.

Happy:  I'm sorry ma'am.  I don't know what's going on, but I have nothing further to offer you in the hospital.  I'll fill out your paperwork for dismissal. 

Patient:  You're going to fill my dee-luu-ded aren't you?

Happy:  No ma'am.  I have a personal policy of not prescribing narcotics for unexplained chronic pain that only responds to dilaudid.   You'll have to talk to your primary care physician about long term management. 

Patient:  F**k you.

Happy:  I don't know what to say to that.

See how easy it is?  It gets easier every year.  Do you find it hard to tell a patient, "I don't know?"