Authored By: Hayley Striegel
Art By: Julia Chen
How would you feel if you went to the doctor and your doctor said, “I don’t know what’s wrong”? That’s a pretty bad look, right? Well, your doctor being comfortable looking bad could just save your life.
The fear of looking bad to patients, colleagues, learners, and even themselves can lead physicians to gloss over their own knowledge gaps, omissions, and mistakes when practicing medicine. Patient Carolyn Thomas, writing about the time she presented to the emergency department with symptoms of a heart attack, shares: “all of my test results that day appeared to be ‘normal’. So instead of admitting this puzzling discrepancy, the doc seized upon an alternative hypothesis as he pronounced confidently to me: ‘You are in the right demographic for acid reflux!’” [1]. Unable to admit to his patient that he did not know what was wrong, he seized upon an incorrect diagnosis, leading to a delay in proper care. In fact, over 200,000 patients die annually due to preventable medical errors [2] such as this one.
So, why do physicians do this? Well, one reason is because patients can feel more comfortable with an incorrect diagnosis delivered with certainty than being told their diagnosis is uncertain [3]. The lay patient, and even others in healthcare, have an impression of physicians as infallible experts, and this takes a toll. Dr. Jordan Grumet recounts explaining to nurses why physicians yell at them over the phone: those physicians inappropriately lash out because of feeling afraid and uncertain what to do. “A look of astonishment and then understanding flashed across a dozen faces. It was like a weight was lifted off their overburdened shoulders” [4]. Many physicians, having been elevated to a god-like status in their work, struggle to cope with the fact that they are only human, which can lead to impostor syndrome and burn-out. However, acceptance among patients, health professionals, and physicians alike that the best physicians should sometimes “look bad” by admitting uncertainty is the answer is a salve for the disease of false assuredness and misdiagnosis.
Before physicians become physicians, they must clear a series of hurdles. Medical school admissions committees scrutinize applications for “flaws” such as a history of depression or gaps in education, so only applicants who hide their “deficits” well become medical students. Once in medical school, students receive grades and are ranked among their classmates based on how their clinical preceptors feel their fund of knowledge in the subject is; if a student doesn’t know something, it’s better to remain quiet. In other words, learning to mask one’s knowledge gaps is incentivized rather than speaking up in order to learn and fill in the gaps. Exam failures are hush-hush, and some students never tell anyone for fear of being seen as stupid by their peers, even though failure is a ubiquitous curricular feature to ensure students master the material. Impostor syndrome runs rampant, yet is a closely-held secret by medical students who feel they do not belong. By the time these students become resident physicians, they have been repeatedly necessitated to hide their deficits to be seen as capable and progress to residency.
Once they become residents, physicians must work at a rapid pace and will inevitably make mistakes and omissions. The omissions they make may not be caught by an attending physician, and if noticed by the resident later, they may feel shame and uncertainty in deciding how to address them, as Dr. Sarah Householder explains in her prose, “Resident Clinic”:
“Now, hours later, I notice her blood pressure for the first time—159/96? How did I miss that? I scan her medications—she was already on 2 blood pressure meds. Was this just the blood pressure cuff? Was she also forgetting to take those medications? This visit was supposed to be focused on diabetes, but shouldn’t I have at least told her that she was still not at goal? I wasn’t scheduled in clinic for 3 weeks—was I even allowed to call patients without running it by an attending?” [5].
The conditions of residency, and the path which led physicians like Dr. Householder to where they are today, make it such that physicians feel shame, fear, and guilt at having made an error or omission and have equipped them to hide their mistakes. For Dr. Householder to call her patient and address her blood pressure could so much as save a life, so the right course of action is clear, but instead she feels doubt, borne from the years she was training to become a physician and, unbeknownst to her, to keep mistakes well-hidden.
It is because of situations like this that being able to “look bad” is an essential life-saving skill that physicians must know as much as CPR, and yet they are conditioned to do the opposite. Medical schools already teach soft skills such as breaking bad news to patients and approaching vaccine hesitancy, but we must add another to the curriculum: tolerating the discomfort of looking bad. It is imperative to teach future physicians to embarrass themselves by calling a patient whose hypertension they missed on initial review, admitting to their nurses that they are afraid, and saying “I don’t know what’s wrong” to their patient with heart attack symptoms whose tests are normal instead of telling her she has acid reflux. Our physicians must know how to look bad — lives depend on it.
References
Thomas, Carolyn. (2014, Jan 3). When doctors can’t say: “I don’t know.” Heart Sisters. https://myheartsisters.org/2014/01/03/when-doctors-cant-say-i-dont-know/
Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024, February 12). Medical error reduction and prevention. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Beck, J. (2016, February 29). When doctors should say “I don’t know.” The Atlantic. https://www.theatlantic.com/health/archive/2016/02/when-doctors-should-say-i-dont-know/471222/ re
Grumet, J. (2014, August 6). Why do physicians behave badly? maybe because they’re scared. KevinMD.com. https://www.kevinmd.com/2014/08/physicians-behave-badly-maybe-theyre-scared.html
Householder, S. (2024). Resident clinic. Journal of Graduate Medical Education, 16(1), 86–87. https://doi.org/10.4300/jgme-d-23-00448.1
