Here’s a story from my radiology residency days that’s still completely relevant: more than a bit discouraging to see how little medical culture has changed since then.
One Saturday in the ER, a friend of mine came into the reading room and put a chest x-ray on my viewbox. Another routine consultation, as far as I could tell.
“Do you see any rib fractures?”
“No, looks pretty much OK. Nothing broken.”
Instead of taking the films down, he left them up and sat in the chair beside me, one arm perched atop its back. “Let me ask you something,” he said. Oh no, I thought, what is this?! His face was very serious, a rare departure from its easy-going norm. “Sure,” I said with growing trepidation. “What is it?”
“How do you count ribs?”
I wasn’t sure I’d heard him right: counting ribs was so basic any first-year radiology resident could do it in her sleep. Surely my friend, a sixth-year surgeon, knew how to do this. He knew what I was thinking, though I didn’t say a word. “I never learned to do it right, and I always have trouble telling which is the first one—they’re all bunched together up there at the top—so I just count up from the bottom, which I know isn’t as accurate. But who could I ask? I’m supposed to know this by now.”
He had a point: medical training is anchored in the assumption that the next guy up the ladder knows what you do not, and that he will teach you. For the senior to admit unfamiliarity with something basic, no matter how irrelevant or small, and ask the junior to explain, would shake the founding trust of this relationship. By the same token, my friend could never confess ignorance to his chief resident, the man one year ahead of him, because that would label him as marginal. Clearly not a viable option for a bright, ambitious surgical resident. And where was he to find the time to read about it?
We tend to trap ourselves in quandaries like this throughout our training when we fail—for whatever reason—to master something at the time it’s first presented. We let it go because we’re busy, or because it doesn’t seem critical, or because we’re afraid to ask a ‘stupid’ question. “I’ll sit down and read about that later,” we tell ourselves, and of course we never do: later brings something else to read, do, learn, all just as pressing. For each of us the sticking point is different: for my surgeon friend it was rib counting, for me it was reading ECG’s, for another friend it was neuroanatomy. The problem doesn’t end once a doctor begins practice—if anything, it’s even harder then. You’re done with training, after all, so shouldn’t you know everything? And of course you want your patients to have confidence in you.
There’s a point beyond which it’s not acceptable to admit ignorance, so we often act as if we know. Any physician who is honest and self-knowing will recognize the hand-shaped bricks that form this wall of assumption and appearance. Dismantling the wall is difficult, reinforced and defended as it becomes over time, but it can be done.
The first step, and probably the hardest for many doctors, is being able to say, simply and honestly, “I don’t know.” This goes against the dense, exacting grain of medical culture, and is threatening to our concept of mastery. At the same time, though, it’s oddly liberating to acknowledge that you aren’t perfect, and don’t need to be. It’s a lesson I relearn often in radiology, a field so vast that no one person can possibly retain it all. Knowing you’ve got a resource, whether friend, mentor, textbook, or search engine, is the key that unlocks the shackle. I was honored that my friend had trusted me to be his resource, and impressed that he’d had the guts to ask.
I raised my left hand to the film and traced along the patient’s spine with my index finger. “You don’t want to count up from the bottom, because not everybody has twelve ribs, and that can really screw you up. So you need to start at the top, and the best way to find the first rib is…”