Clinical Humility and the Limits of Medical Knowledge
Being willing to say “I don’t know” can help physicians build trust with patients and one another. A friend of mine has thyroid cancer. He went to three specialists when he received his diagnosis.
The first recommended a full thyroidectomy to remove the entire tumor. The second recommended a series of two smaller operations to remove the tumor rather than a single surgery. The third recommended chemotherapy followed by two smaller operations, but not removal of the entire tumor, which he felt could result in my friend losing his voice.
All three seemed confident in their prognosis. Not one uttered the words, “I don’t know.”
One of the greatest challenges in medicine is the desire for clinical certainty. Our patients demand it. Our colleagues demand it. Many physicians, determined to offer their patients certainty, shy away from admitting that all too often they cannot offer assurance. Yet anyone who practices medicine knows that “it depends” is often the most accurate answer we can give. This problem was on prominent display during the COVID-19 pandemic, when many experts responded to this time of grave ambiguity by offering well-intentioned but misguided certainty. Rather than creating a sense of calm, they contributed to an erosion of trust in health care and public health when facts and circumstances changed quickly.
As I’ve reflected on how clinicians responded to the COVID crisis, I’ve come to believe that being comfortable with saying “I don’t know” is one of the most important ways we can build trust with our patients and one another. All of the physicians my friend saw are excellent practitioners who are committed to helping him. But they, like so many doctors, have likely been trained to perpetuate the myth of the all-knowing healer. I believe medical education must do more to explode this myth so that we can serve our patients more effectively.
When I was at Harvard Medical School in the early 2000s, Daniel Lowenstein, MD ’83 — then the dean for medical education — introduced a new curriculum that emphasized what I’ve come to think of as clinical humility. In the 1980s and 1990s, physicians were trained to project total confidence in their vast medical knowledge, but people like Dr. Lowenstein argued for a different approach. Today, mastery does not mean knowing a lot of information; it means synthesizing information. Board exams and certifications are now open-book exercises, and the growth of e-consults among clinicians signals a willingness to ask questions.
I’ve found that this sort of humility is a great trust-building managerial skill outside of clinical settings. But despite changes over the years, I still find such an approach rare in medicine. To help me think about why that is, I reached out to a handful of my fellow HMS alumni to gauge their experiences with what I call “clinical humility.” Their thoughts, I believe, offer a great starting point for what I hope will become a broader conversation on this topic.
Ruma Rajbhandari, MD ’07, HMS assistant professor of medicine at Massachusetts General Hospital and a gastroenterologist, wishes that clinical humility had been a more prevalent element of her medical school training. “You only start seeing it and learning it once you practice,” she told me. “The focus in med school was coming to the right diagnosis and having an answer.” There are a lot of gray areas where you can’t follow the book, she added. “I think the good clinicians are the ones who are apt to say, ‘I don’t know,’ and patients appreciate that.”
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