There are three words that many patients never hear a doctor say: "I don't know." A physician's reluctance to utter this phrase may lead to mistakes and misdiagnoses.
That's what happened to Maryland healthcare advocate Starr Mirza, who suffered years of inadequate medical care as a teenager in response to fainting episodes. A series of doctors were clearly baffled, but no one ever admitted that. Instead, her symptoms were dismissed, and a diagnosis was concocted from the "all in her head" column: She was a drama queen who needed psychiatric care. (The psychiatrists she consulted said there was absolutely nothing wrong with her mental health.) It was only after going into cardiac arrest at age 23 that Mirza learned she has a life-threatening heart condition, which has required multiple surgeries and constant monitoring. She told me: "It is so much worse to make someone feel like they're crazy than to just say, 'Sorry, I don't know.' I've told doctors they need to learn to say, 'I don't know.' Patients will respect you."
Nearly all of the female patients I interviewed for a had equally harmful encounters with healthcare providers who did not listen to them -- or worse, did not believe them -- when they sought help during health crises. Many were given a diagnosis of depression, stress, or anxiety, without having their physical problems properly evaluated. None of these women were ever told something along the lines of: "I'm sorry, I'm not sure what's going on. Let me consult with a colleague who might have answers."
Reluctance to admit uncertainty is perhaps rooted in a form of interrogation medical schools use on students. Known as "pimping," the practice is modeled after Socratic grilling, in which students are put on the spot during rounds, often in front of colleagues and patients. As explained by the public radio show, "," pimping is a common routine in hospitals: "But not that kind of pimping; the term pimp, possibly from the German pumpfrage, meaning 'pump question,' refers to the method of tough quizzing that doctors put their young residents through. It generally straddles the border between rigorous initiation and plain bullying."
Family physician and patient experience researcher Anjana Sharma MD, MAS, who works at the University of California San Francisco, says the intense questioning reinforces the fraught notion that doctors need to have total recall of the vast body of medical knowledge: "It is on your shoulders to have the answers...I don't think it's typically mal intent. It's genuinely feeling this unrealistic responsibility of 'I'm a doctor and I should know.'"
She believes that the stressful Q&A format creates an unsafe learning environment: "The impulse is to provide any kind of answer; it's unfortunately much more about performance than about the patient."
Complicating this dynamic are the expectations of patients, who want doctors to have the tools to respond to and address any health condition. This belief has been shattered during the pandemic. No one was prepared for the all-encompassing horrors of COVID-19. With each surge, heroic healthcare workers have struggled to stay afloat in a sea of death and despair. Sharma says that the pandemic has caused many doctors to be "humbled and confused. The information has been unfolding so rapidly."
Even now, more than 2 years into the siege, there are still a lot of unknowns. People suffering from long COVID find that there is no easy cure for the never-ending ailment. "Many doctors can't handle the uncertainty," says Sharma. "It would be nice to give a simple, concise explanation: 'This is what's happening.' But that's not the way that medicine and health always play out in real life, and definitely not with COVID."
Family medicine physician Kelley Butler, MD, MPH, a first-year resident at Zuckerberg San Francisco General Hospital, notes that her generation of doctors has had to learn that "we need to rely on our pharmacy colleagues, our nursing colleagues, our social workers, because they harbor knowledge that we just don't have...In the past, the idea of saying 'I don't know' was seen as not allowed. The treatment team was designed as the doctor knows and no one else does...There was no such thing as the patient being a person with knowledge."
Butler, who graduated from medical school in 2021, believes that today's young doctors are more aware that patients should be part of the equation, providing crucial information about their own bodies and health history.
Best-selling author Laura Hillenbrand, who was misdiagnosed for years before learning she has debilitating chronic fatigue syndrome, how liberating it was when a doctor admitted he did not know what was wrong with her, although he had no doubt that she was very ill: "That took humility for him to say. I am so grateful for it. I walked out of there happy, even though he said, 'I can't treat you. I don't know what to do for you.' But simply telling me, 'I respect you, and I have a limit to my understanding of disease,' was a beautiful thing."
Sharma agrees that it takes courage and vulnerability for a doctor to be honest and say: "I don't know what this is right now but we're going to get more information, and I'm with you until we figure this out."
Compassionate words like these can uplift the spirit and offer hope. Every patient deserves to hear them.
writes about health and culture and is the author of the 2019 book, . An updated paperback edition was published in February.