As a doctor, it is unnerving to confront an ailment that you don’t immediately know how to conquer. All those years of training, all those hours of study — and yet at some point, every doctor is confronted by one terrifying prospect: you will never know everything. When that happens, you have two options. Tell the patient the truth, however uncomfortable that might make you feel, or try to come up with an answer that “possibly” captures the diagnosis.
The latter is tempting. Not being able to give a clear answer can feel as though you’re failing to fulfill your responsibility as a trained professional. The patient is looking to you for answers, and that pressure is daunting. Reflexively, you want to reassure them by showing there are no gaps in your knowledge. Of course, that’s impossible — with all the changes in our environment, lifestyle, and food, there are new diseases developing all the time.
From eleven years of operating my own practice, I can tell you that there are times when every physician has the right to be dumbfounded. Despite all the advances in the field, there are still many shadowy corners of medicine that are a mystery. And that’s OK. In fact, I’ve discovered that one of the most important things a doctor can say is “I don’t know.”
In the early days, when patients would come in with vague, but troubling complaints, I would conduct what I thought at the time were very extensive tests — an analysis of their blood and urine, a detailed physical exam, and then, if warranted, radiological studies. When they returned a week later only to discover their results were all normal, I was frequently surprised by their frustration and sadness — and, on occasion, by their tears. It seemed like good news to me.
But when I asked, I’d hear the same thing time and time again: they had hoped to finally have an explanation for their suffering. Even an upsetting answer is often better than no answer at all.
So I did the best thing a doctor can do in that situation. I looked a little deeper.
When a patient appears “normal” but is in distress, that’s when we need to get creative. I expanded the scope of my tests, hunting diligently for hormone and vitamin deficiencies, Lyme disease and coinfections, unusual thyroid conditions, and whatever else I thought might manifest in the symptoms a patient was presenting. In doing so, something special happened. I got to fall in love with medicine all over again. When I graduated from medical school, I knew very little about Lyme, vitamin and hormone deficiencies, or endometriosis. Now the management of these conditions is pivotal to my everyday practice.
As a physician, when you’re unsure of what’s going on, you can call specialists and hear about the latest diseases they’re seeing and the treatments they’re offering. You can search through the most recent journal articles and case studies. Sometimes, you may need to go back to basics and pull that old faithful medical textbook off the shelf. It’s a chance to reconnect with that excitement you felt in med school when the intricacies of the human body were first revealed to you.
So why don’t we allow ourselves the space to continue learning throughout our careers?
Our training cannot prepare us for the constantly shifting landscape that is modern medicine, and so we need to adapt our role to shift and grow with it. When facing these newly evolving medical conditions, doctors have to join forces with the patient and walk side by side with them to do some serious detective work. And letting the patient know that empowers both them and you.
Saying “I don’t know” is not an easy thing to do. The medical culture we work in makes it difficult to deal in maybes instead of absolutes. But the consequences of an incorrect or incomplete diagnosis can be far-reaching, breeding mistrust that can be hard to come back from. Worse, you might overlook some clues and symptoms of the patient’s true condition that may lead to many more months (if not years) of their suffering.
Imagine you are suffering and you don’t know why. When you turn to the medical world for help, well-meaning doctors try to put you at ease by telling you that you’re “fine” and “It’s all in your head.” Women in particular hear that last one far too often, and it can dissuade them from seeking the help they desperately need. When you hear this from your doctor, a person you trust with your life and well-being, where else can you turn to relieve your pain and suffering? Some patients are driven to dangerous off-label medicines and treatments. Others find that their families and friends start to cast doubt on the validity of their complaints and symptoms, since, after all, a doctor dismissed them, and surely the doctor knows best. Although no doctor willfully intends for this to happen, it can lead a patient to feel isolated, depressed, and — in some extreme and deeply tragic cases — even suicidal.
So when a challenge walks through your door, you should relish it. It’s a chance to prove your chops and help another patient in need. To fulfill the oath we all took, doctors need to be ready to roll up their sleeves, put aside their egos, and partner with their patients. When it comes to vague but disabling symptoms, sometimes you will need to wear the dual hats of doctor and detective. And I know, this can be hard — not least because our current health-care system doesn’t allow for such time-consuming endeavors and we’ve all been trained in a culture that cautions us against telling patients when we’re unsure. But we owe it to our patients, and to our profession. We have to try.
Sandra Gelbard, MD, is a board-certified internist in New York City. Her practice is focused on disease prevention, cholesterol management, and individualized vitamin supplementation.