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When to say you don’t know

By Dr Muiris Houston - 14th May 2023

slow medicine

Do we need a ‘slow medicine’ initiative to bring about a more humble and thoughtful approach to what we do?

“Oh Lord it’s hard to be humble

When you’re perfect in every way….”

Mac Davis

I’m not a huge fan of country music, but some songs easily become ear worms. This song by Mac Davis was released in 1980 and, for some reason, has stuck in my head.

Just for the record, I’d like to add that I’m far from perfect and, while I probably haven’t achieved it much, I value humility as a trait.

It’s probably fair to say that the field of medicine has never been famous for its humility. Perhaps we have been slow to adopt our ignorance and say to patients, “I don’t know.”

Martin Greenwald, a US psychiatrist writing in the Substack Sensible Medicine describes a patient he sees who remarked following a recent string of frustrating and dissatisfying appointments with various specialists: “How is it that doctors can act with such arrogance when so many of them clearly don’t know what they’re talking about? I don’t think I’ve ever heard a doctor tell me ‘I don’t know’. Your profession has a serious problem with unearned confidence.”

Is it that we are not asked often enough to justify our reasoning and decisions? It’s so easy to react defensively when asked to do so, giving the lie to the idea that we really understand what we’re talking about.

Greenwald references Epictetus – a Greek Stoic philosopher who lived almost 2,000 years ago – as someone who has good advice for modern physicians. The philosopher stressed to his students the central importance of humility in the process of learning. “The task of philosophy was, for Epictetus, fundamentally about living well and fully realising our humanity as rational creatures. Epictetus understood what was at stake: For the arrogant student does not simply fail to learn philosophy, he fails to develop himself as a person, condemning himself to a life of ignorance and unhappiness,” Greenwald writes.

Admitting one’s ignorance is the first step in acquiring any kind of knowledge, and medical knowledge is no exception. But not all kinds of knowledge and expertise are demonstrable to the same extent, in the same ways, and with the same precision.

As a follower and teacher of narrative-based medicine, I have learned the value of narrative humility. Along with narrative knowledge and narrative competence, it is one of the key skills we need to practise narrative-based medicine.

Dr Sayantani DasGupta, who works with narrative medicine guru Rita Charon in Columbia University, was the doctor who first pointed out how important an attribute humility is. Tellingly, she described narrative humility as “a response to efforts at clinical mastery, including some well-intentioned ones”, which has always seemed to me to be a well-aimed criticism. It emphasises the patient’s ownership of their own story and is a reminder that doctors can’t just take a patient story and run with it.

One of the advantages of practising narrative-based medicine is that it makes you slow down in your interactions with patients. Not slowing to the point of inefficiency, but facilitating the tuning out of noise and allowing a greater focus on your patient. The virtues of patience and humility are intimately related. And the combination of both makes it easier to say “I don’t know”, where appropriate, to patients and relatives questions.

The ‘slow food’ movement has been very effective in changing peoples views and eating habits. Do we need a ‘slow medicine’ initiative to bring about a more humble and thoughtful approach to what we do? And, in moving in this direction, might we nudge patients away from a mechanistic and ‘cure me now’ attitude to healthcare?

Greenwald, in reflective mode, says: “For my part, I try to remember that a physician is little more than a temporary custodian, stewarding patients toward health with the relatively crude tools at our disposal. I recall that the great majority of factors affecting the outcome are beyond my control… I recall that I am only one thread in the vast causal chain of someone’s life and that their improved health may owe less to my own intelligence than I would like to think.”

But, as Mac Davis reminds us, that may be easier said than done:

“Oh Lord it’s hard to be humble

When you’re perfect in every way

I can’t wait to look in the mirror

Cause I get better looking each day

To know me is to love me

I must be a hell of a man

Oh Lord it’s hard to be humble,

But I’m doing the best that I can.”

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