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“The game was to appear smart”

Never could reach the point where I could assess how smart I really was - clinical decision making was at the nexus of personality-biases.

Most clinicians are “right” most of the time but even that in unmeasurable.

You accurately tracked my 40+ year career.

If you assume everyone thinks you should know everything even though that is irrational, it leads to good and bad decisions.

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Great story! Thanks for sharing it.

Maybe this could help too:

Song and Video called "Who can tell me the truth?" (In memory of young Canadians who died unexpectedly since January 2022):

https://whocantellmethetruth.ca

(direct link to video: https://youtu.be/F4AwuZn___E)

This is a new approach to reach those who don't suspect anything - through music combined with official stats.

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May 24, 2023Liked by Adam Cifu, MD

As a young, "I know everything" nurse I hated to hear those cheesy statements, 'the older you become the more wisdom you have'. 'Youth is wasted on the young'. Now, as a senior citizen, my insight is more acute and clear. I can't get enough learning. I know that I know nothing. I listen to doctors any and every chance I get so I can learn from them. I am part of Sensible Medicine, Medscape, podcasts from Dr. Prasad and any others like him, ie: Dr. Cifu, etc. I look back and cringe at how little I knew and how full of myself I acted.

Spinning off of that, there is a place, or there should be a place for the older, wiser, more experienced doctors to teach the up and coming physicians what they've learned. Crush Syndrome - not only can the older, more experienced doctor teach the medical/physical/chemical processes but can recount that 34 yof in his ER 25 years ago and how that scenario played out. He/she can explain the 4 stages of MI and infuse the moral, statistical, situational, personal aspects of it. Drawing on real life experiences enhances the learning of the mechanical, impersonal aspects of medicine. Every young med student should be humbled by the sharing from their mentors.

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May 21, 2023Liked by Adam Cifu, MD

At physics talks, Nobel Prize winners are often the only ones with enough confidence and understanding to ask basic questions. Most others are even more lost and unwilling to show it.

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May 20, 2023Liked by Adam Cifu, MD

This seems to be true for all professions. Made my day. Great reflection!

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May 20, 2023Liked by Adam Cifu, MD

Certainly appreciate your honesty.

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May 20, 2023Liked by Adam Cifu, MD

It certainly has been my experience that the confines of "pimping" revolved around questions that the senior physician could answer. I saw attending physicians get acutely uncomfortable at the suggestion that they didn't know something.

For example, I was on a rheumatology rotation and was asked why I didn't do a tender point exam on a patient and I replied that the exam was removed from the most recent guidelines. "How else can I get an objective measurement of the patient's clinical progress?" I was asked, to which I answered in as many words that I had been to several NIH pain consortium meetings where the idea of using tender point exams had been dismissed as pseudoscientific bunk. The objective component of the physical exam was abandoned because the leading experts in the field concluded that it was impossible to objectively measure fibromyalgia, so a purely subjective questionnaire had become the standard, in acknowledgement of our collective ignorance. The rheumatologist was not thrilled with me.

The underlying dynamic here is that there's a strong incentive to conform. I resisted it to some extent, but I would agree that it's a problem. My (Australian) medical school did a study on "uncertainty tolerance" among medical students, and I suspect that most of ours was far too low.

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First, thank you for sharing your journey. Others have done so too, such as a book called "Rising from the Dead" by Dr Humphries.

Second, you ask this question: "how can we figure out a way to instill greater confidence and security in our learners and doctors from the earliest stages?"

You also said that you learned by asking questions of all of those around you. Is that the smartest thing to do though?

The birth of my first child (which was classified as "normal" by my doctor) left me in a state of shock akin to emotional rape. Yes, that is an emotive term. In a defrag session with my doctor, who spent quite some time assuring me that my experience was "routine", I asked to borrow his obstetrics textbook which was on a shelf right beside him.

"Sure" he said passing it to me, "But you won't understand it."

Once home I quickly realised that this large hardback book had never been opened. Also, the page trimmer had missed some pages, so I had to use a thin sharp knife to cut the fold to read the pages.

I returned to the doctor some weeks later with a list of questions, which he answered as per exactly what had happened to me.

Then opening his book at pre tagged pages, I read him what should have happened which was diametrically opposed to his answers.

He looked shocked. So I asked him how it was that he came by his knowledge of obstetrics, and he said exactly what you said. That he was so busy that he picked the brains of his colleagues all around him. And yes, he admitted that he had never read the book when presented with the proof that he hadn't.

I then asked him some more questions, like, "Where do you think your peers, whose brains you picked got their information from?" That led to silence. I followed up with "Do you think that maybe they never read their textbooks either, and what you did was just word of mouth practice?"

He did say that he had spent a year in Nepal where he spent a lot of time watching women deliver babies in a vastly different manner without contributing much because he didn't know the language. He also said that "their way" of delivering babies was "uniquely Nepalese". Which was astonishing, because as far as I know, Nepalese women's bodies are the same as women everywhere.

If he had applied what he saw in Nepal, perhaps his patients might have benefited... because most of those concepts were what was in his obstetrics textbook.

Maybe listening to your peers might not have been the most accurate respository of useful medical information....

To answer your question, "how can we figure out a way to instill greater confidence and security in our learners and doctors from the earliest stages?" perhaps the most important things doctors need to cover first, is to trust how the body really works in all aspects, nutrition, epigenetics, mind-body connection, the importance of "words" (Not using them to cut people off at the knees) what is known about the immune system and the gaps in that knowledge... - all the stuff about how the world actually works at the street level.

ONLY then, should the "intervention" model be introduced. Right now, the function of the medical system seems to be grounded in algorithms which usually lead to drug prescription, or what others call "cut slash and burn", all of which is very expensive.

Medicine needs to come back to the core mandate which is helping patients to take responsibility for health from the beginning, in a meaningful way.

Then doctors may have much more confidence, because that results in a very meaningful contribution to how patients feel about themselves.

The only problem with such an idea is that it puts big pharma in the trailer, rather than behind the steering wheel.

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May 19, 2023Liked by Adam Cifu, MD

So much that resonates here, thanks for sharing this. No-one knows everything and over the years, as you specialise you naturally get more distance to the earlier generalist knowledge.

It’s funny that some industries teach the importance of saying “I don’t know” regardless of your years of practice. It’s arguably the most empowering opportunity to learn -in context-from and/or together with your peers and colleagues.

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May 19, 2023Liked by Adam Cifu, MD

I enjoyed the essay, stages of learning and growth as a physician.

The wonderful thing is the more one knows the more they realize what they don't know. Knowledge gaps become apparent. The Dunning- Kruger effect seems very accurate!

My favorite people to learn from are those who are dedicated to their field of study and always pursuing more knowledge and correcting previous errors with humility and generosity.

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As is often the case, I tend to fall back on the wisdom of Will Rogers: “The problem ain't what people know. It's what people know that ain't so that's the problem.” What I see, in our culture where we are essentially ordered to obey "experts" we have trained several generations to blindly accept what they're told is fact. Given the amount of information medical students have to ingest, it seems all too easy to fall into the habit of never asking questions, a habit reinforced by those responsible for providing that information treating those who do ask questions like fools.

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Very transparent, Adam. I would ask fellow readers and you to contrast your transparency and humility with the image projected by Anthony Fauci. He recently gave the commencement address at the Washington University School of Medicine and gave an idealistic address on pursuing the truth to help patients, all well and good. However, he did NOT add any lessons he learned about missteps that he took and incorrect policies (mandatory vaccines) he embraced during the pandemic. Sadly, the entire audience gave him a standing ovation. I am afraid that the physician community has earned the disrespect that it has received by acting like lemmings. Adam's humility is a far better prototype for the fallible and limited people that we all are.

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May 19, 2023Liked by Adam Cifu, MD

Pretty accurate, Adam. Re: House of God, recently read it, has a few nuggets of truth, a few laughs, that's about it.

I routinely peppered my med students with questions during bedside teaching, not to embarrass them but to gauge their fund of knowledge and develop critical thinking. I encouraged students to challenge dogma, but then follow up with relevant literature to buttress their views. Teaching is learning. After a lifetime in medicine, there is much we know and even more we don't, if we're honest with ourselves.

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May 19, 2023Liked by Adam Cifu, MD

I think it takes being comfortable with not knowing everything to be a good generalist. When I was training it seemed a lot of the reason colleagues would sub specialize was to be able to be that authority on knowledge of a subject. One’s comfort level with the unknown has to be balanced though with good clinical judgment to be able to avoid pan consultation yet provide appropriate care.

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May 19, 2023Liked by Adam Cifu, MD

So true, and necessary for open discussion to move us forward for better practice. I remember a time when Morbidity & Mortality monthly meetings in the hospital afforded group learning opportunity for medical staff - still leaned towards “blame as a quick solution”, but often resulted in deeper understanding and healthier teamwork. Similar Code Debriefing meetings with ER staff - those went away in the 2000s. Seemed to be replaced by “Flow Model” and “inclusion” focus....

One way to truly change medical education would be a course in the first semester on this subject - learning how to learn, the inevitability of knowledge gaps and changing practice standards, and the psychology of humility/honesty/integrity

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May 19, 2023Liked by Adam Cifu, MD

Thank you for this. My son just took the mcat and will begin med school in 2024. (Getting his Masters this year). I’ll be passing this on now.

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