When doctors can’t say: “I don’t know”

by Carolyn Thomas    ♥  @HeartSisters

Pity the poor Emergency Department physician who first studied the results of my cardiac diagnostic tests. Despite my textbook heart attack symptoms of central chest pain, nausea, sweating and pain radiating down my left arm, 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!”

I was sent home from hospital that morning (feeling very embarrassed about having made a fuss over nothing) with his directions to make a follow-up appointment with my family physician to get a prescription for antacid drugs (to treat what turned out to be a misdiagnosis of indigestion).

Part of the problem with this scenario is the reluctance of some physicians to admit that they just do not know.

Dr. Stuart Foxman has compared doctors who are reluctant to say “I don’t know” with the same phenomenon seen among business executives. In his Doc Talk column for the College of Physicians and Surgeons of Ontario, he quoted Stephen Dubner and Steven Levitt, authors of the book Freakonomics, who suggested that many senior people in business rarely admit to not knowing something:

“If the question at hand is within their realm of expertise – even if they have no clue of the answer – they’ll just fake it.”

Why? The authors believe that people may feel that they’re always expected to have an answer, or worry about looking bad to others. This is one of the most destructive personal factors, because it hinders actual learning.

And the world of medicine is not immune, warns Dr. Ivan Silver at the Centre for Addiction and Mental Health in Toronto.

“Doctors don’t find it easy to say ‘I don’t know.’ There’s a tradition of knowing the answers and coming up with them quickly.”

The problem, says Dr. Silver, comes when doctors don’t disclose that they don’t know, or  – like my Emergency Department physician – they confidently pronounce some kind of definitive answer pretending they do know.

Despite seeing a patient in front of him presenting with classic Hollywood Heart Attack signs, he seemed unable or unwilling to make sense of the confusing difference between my significant cardiac symptoms and those “normal” cardiac diagnostic tests. So rather than admit me for observation, his choice instead was to grasp onto the alternative hypothesis of GERD. Even I knew that pain radiating down one’s left arm isn’t a sign of acid reflux, but I actually felt relieved by the misdiagnosis at the time (I’d much rather have indigestion than a heart condition, thank you very much!) 

And the person assuring me that “It’s not your heart!” happened to have the letters M.D. after his name.

The origins of this kind of over-confident behaviour go back a long way, as Dr. Silver explains:

“Go back to teaching rounds, where medical students are grilled in front of patients and peers. An answer is anticipated, and ‘I don’t know’ is not rewarded.”

Speaking of medical school training, some critics blame med school culture itself as the beginning of the end in being honestly willing to admit ignorance, as explained by Chicago physician Dr. Alex Lickerman, author of The Undefeated Mind: On the Science of Constructing an Indestructible Self.  He wrote:

“You first need to know how doctors are trained to think. Medical students typically employ what’s called ‘novice thinking’ when trying to figure out a diagnosis.

“They run through the entire list of everything known to cause the patient’s first symptom, then a second list of everything known to cause the patient’s second symptom, and so on. Then they look to see which diagnoses appear on all their lists and that new list becomes their list of ‘differential diagnoses.’ It’s a cumbersome but powerful technique, its name notwithstanding.

“A seasoned attending physician, on the other hand, typically employs ‘expert thinking’, defined as thinking that relies on pattern recognition. I’ve seen carpal tunnel syndrome so many times I could diagnose it in my sleep – but only learned to recognize the pattern of finger tingling in the first, second, and third digits, pain, and weakness occurring most commonly at night by my initial use of ‘novice thinking’.

“The main risk of relying on ‘expert thinking’ is early closure – that is, of ceasing to consider what else might be causing a patient’s symptoms because the pattern seems so abundantly clear.”

Dr. Allen Frances, writing in his Psychology Today column called “What Should Doctors Do When They Don’t Know What To Do?”, observed:(1)

“There is a big disconnect between the daily enthusiastic reports of great new research results and the fact that treatment outcomes have improved only slowly and selectively.

“Clearest example: we have done a lot more to defeat cancer by dramatically reducing smoking than through the entire expensive 40-year research war we have waged against it.

“One negative side effect of scientific drum-beating is the unrealistic expectation (held by doctors and patients alike) that every medical presentation can be accurately diagnosed and effectively treated.

“When, as so often is the case, this expectation is defeated by the hard reality of our limited knowledge, doctor and patient are both likely to feel grave disappointment and the relationship between them may become uncomfortable and unproductive.”

Dr. Frances also quotes Maryland neurologist Dr. Nicholas Capozzoli, who says:

“In my neurology practice, I often can’t make a specific diagnosis even after taking a careful history, doing a thorough physical exam, and ordering all the appropriate diagnostic tests.

“Such uncertainty is inherent in most of medicine – it is sad but true that lots of problems elude our current medical tools and knowledge.

“This is tough on patients. Understandably, they want (sometimes demand) clear answers about what’s going wrong and a treatment recommendation that promises cure or at least substantial relief of symptoms. My challenge is to be helpful and to maintain a healthy doctor/patient relationship even when I can offer no clear answers to diagnosis or treatment.

“This isn’t easy or natural. Doctors tend to be uncomfortable admitting uncertainty to themselves or to their patients. Too often, they feel it’s a threat to their skill, authority, or expert status to say they simply don’t know what’s causing the symptoms or that there is no magic bullet to cure them.

“Often enough, doctors default to blaming the patient with an explicit or implicit ‘it’s all in your head’.”

Blaming the patient is, as I’ve previously observed here, not only extremely upsetting to the patient, but also potentially dangerous.

Dr. Allen Frances seems to agree:

“The difficulty of accepting uncertainty is just as strong today as it ever has been. It leads to excessive testing, quack treatments, or blaming the patient.”

Consider also the distressingly common experience of female heart patients whose cardiac symptoms have been dismissed as merely those of an “anxious female“ if their doctors are unable or unwilling to link the symptoms to a cardiac cause.

Some of the most popular cardiac misdiagnoses that heart attack survivors have told me about include wrong guesses like indigestion, menopause, stress, gall bladder issues, exhaustion, pulled muscles, dehydration and more.

But perhaps the most distressing misdiagnosis to trip from the lips of an Emergency Department physician is anxiety. This one single word is instantly both dismissive and embarrassing.

And worse, to have the diagnosis of ‘anxious female’ recorded permanently on a woman’s chart virtually guarantees a definitive psychiatric stereotype for all future medical visits.

Dr. Wendy Levinson at the University of Toronto Medical School reminds us that “uncertainty is very different from a lack of knowledge”. As much as patients may want answers, the idea that the doctor knows everything is an old model, she says – an idea which fewer and fewer patients believe anymore.

Trusting that every physician will somehow magically know everything about the millions of cells in our bodies that could be responsible for our physical symptoms is indeed an unrealistic expectation, as Dr. Nicholas Capozzoli sums up nicely:

“After 40 years of practicing medicine, I’ve become quite comfortable saying that I simply don’t know what’s causing the problem. It serves my patients well to admit that things are still too unclear to call.  I make clear that I take their symptoms very seriously and appreciate how much their lives are impacted by them.”

“Given how complicated are our brains and bodies, it is not at all surprising that medical science is far from understanding all of their workings.

“I emphasize that we are waiting for science to catch up, that lifestyle changes can make a big difference, and that I am on their side. This goes far in maintaining personal dignity and the integrity of the doctor/patient relationship.”

“But confronting the reality of uncertainty almost always beats the creation of a false certainty.”

And Dr. Stuart Foxman suggests offering this reassuring bit of truthfulness to patients:

“I don’t know – but I’ll do my best to find out for you.”

♥  Image of Mimi & Eunice written/drawn by Nina Paley

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1. Allen J. Frances, M.D. “What Should Doctors Do When They Don’t Know What to Do? Uncertainty certainly beats false certainty.” Psychology Today. June 24, 2013

Q: What’s your reaction to doctors who say “I don’t know”?

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NOTE FROM CAROLYN:   I wrote much more about diagnosis and misdiagnosis in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 20% off the list price).

See also:

Six rules for navigating your next doctor’s appointment

When patients are seen as “The Enemy”

How to communicate your heart symptoms to your doctor

Misdiagnosis: the perils of “unwarranted certainty”

Experts: Why so wrong so often?

When you fear being labelled a “difficult” patient

The ’18 Second Rule’: why your doctor missed your heart disease diagnosis

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