EM Mindset: Not knowing

This post was written for the fantastic EMDocs.net EM Mindset series.  If you have not come across this series before, I strongly recommend checking it out. You can find it here. Thanks to Alex Koyfman and Brit Long for their edits.


The EM Mindset series is one of my favorite in the FOAM world. A lot has already been said about the makings of great clinicians. When I first sat down to write, I wondered whether there was really anything left for me to say. What makes a great emergency physician? What could I add that hadn’t already been said? Am I worthy of adding my thoughts? I honestly don’t know.

I don’t know… but I’m comfortable with that. I am comfortable acknowledging how much I don’t know; how much there is to learn; how much I can never know.

I believe that acceptance of ignorance is an essential quality of great emergency physicians. The doctors I admired throughout my training – who I still admire today – were all comfortable with their ignorance. They didn’t try to hide it. They were quick to say, “I don’t know”. They engaged with their ignorance, not trying to defeat it (an impossible task), but simply trying to manage the impacts of what they didn’t know. In my hour of need, I don’t want the doctor who knows everything. I want the doctor who recognizes how little he/she knows, but is willing to do everything necessary to fill in the gaps. There is just so much that we don’t know, and it does us no good to pretend that we do.

We don’t know our patients’ minds. We can be quick to judge. Why, when we are so busy, did this mother bring in her child with 1 hour of fever? Why has this diabetic not been taking his metformin as prescribed? Why are you here? But we don’t know. We don’t know the daily fear that exists after already seeing one child die of meningitis. We don’t know what it’s like not to be able to read a medication label, or to be unable to afford essential medications. We can’t know – unless we ask.

We don’t know what is going on with our colleagues. We might see the anger or the rudeness, but we don’t necessarily know about the divorce, or the hours of sleep lost with a sick child. We don’t know their perspective, and our ignorance reminds us to address our colleagues with compassion.

We don’t know what is going to happen. There is no crystal ball. We know that we will send patients home who will come back with a missed MI; a missed PE; a missed cancer. We know that we can’t find them all; that if we aim for perfection we will fail and hurt patients along the way. We don’t know the future, but this ignorance reminds us how important it is to talk to our patients. Cautions us to be careful in our instructions about when to come back. Reminds us to teach our patients as much as possible.

We don’t know what is going to come in tonight. As we walk up to the hospital each day, we can’t know if today is the day we will diagnose an infant with congenital heart disease, or perform a surgical airway, or manage a mass casualty. We can’t know if our sickest patient of the shift will be 100 years or 100 minutes old. This ignorance reminds us to be prepared. It drives us to train, to learn, to strive to be even better.

We don’t know whether this treatment will work for this patient. Aspirin reduces mortality in STEMI, but only for 1 patient out of every 40. The others are going to be fine without aspirin, or are going to die anyway. We can’t know in advance when our treatments are going to help. This ignorance reminds us to discuss these decisions with our patients. It reminds us to always consider the potential harms as well as the potential benefits. And it reminds us to reassess our treatment strategies so we can stop if we aren’t helping or if we are causing harm.

We don’t know what our test results really mean. Despite the language we use, tests don’t rule in or rule out. There is no perfect test. There will always be false positives and false negatives. Tests can’t tell us the truth. They only shift our place in a complex world of probabilities. We can’t know which patients represent false test results, and this ignorance again reminds us to speak to our patients. It reminds us to consider our uncertainty when judging potential benefits. (The harms of treatment exist whether or not we are right about the diagnosis). It reminds us to be willing to reconsider our diagnoses.

We don’t know the foundation of our practice. Science is a methodology for exploring the world, but it does not define truth. This is especially true in medical science, where the number of possible observations is always extremely limited, and the degree of complexity almost incomprehensible. The venerated p value does not define truth. Scientific studies, much like our diagnostic studies, simply shift the probability that our understanding is correct. This ignorance reminds us not to be dogmatic. It cautions us to continue to examine our beliefs, even those that we hold most dear. It reminds us not to be surprised or angry when it turns out that we have been wrong.

We don’t know what is right for each patient. We can know numbers: that antibiotics might shorten the course of bacterial pharyngitis at the cost of diarrhea. But we can’t know the importance for each patient. Which outcomes matter to this patient? How will the symptoms affect their lives? How do we balance mortality against disability; time off work against pain; time with loved ones against expensive ICU care? Our ignorance reminds us of the importance of shared decision making to allow patients to judge the relative importance of harms and benefits for themselves.

We don’t know, but we can find out.

There is so much that I don’t know, but as long as I keep my ignorance at the front of my mind, and remain curious and compassionate, I think I can continue to grow into the emergency physician I have always wanted to be.


If you enjoyed this post, you might also like my post about communicating diagnostic uncertainty.

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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