The Ex-Doctor's Diary: Knowing What You Don't Know

I recently considered entering an essay contest run by a professional society for health executives. I knew being a doctor would enhance my entry. I could pull together clinical issues like pay for performance and consumer-based healthcare, while expanding on a few concepts I'd been discussing in my health administration graduate classes about risk-bearing and Wennberg's small-area variation theories. I was already trying to figure out how to manage the $3,000 prize and deciding whether my husband should go to Chicago with me to accept my award, when I went to see a professor and leader in the department to tell him about my idea.

He put my visions of a snowy night on Michigan Avenue on hold.

He told me to wait until I had a few more classes under my belt; I wasn't ready to pull together high-level concepts because I hadn't learned some of them yet. For example, I needed to apply some statistics and economics to my idea.

I've faced other humbling situations like that one over the past several months in my MHA program. It's not a lot of fun. After I thought about this most recent experience, however, I realized it was a huge relief. Now I can stop pretending to have all the answers and start asking questions instead. I think it's a lesson other physicians can benefit from, too. At least when it comes to business, we shouldn't always expect to know what we are talking about. Sometimes, asking questions is the smartest thing to do.

KNOW-IT-ALL MDs

I left clinical medicine and began graduate school, but I didn't leave behind feelings of entitlement and personal expectations of success. I was used to doing things right the first time. I was used to memorizing and regurgitating information while focusing on an individual patient. Medical school is partially characterized by rote memorization of large volumes of information. By the time I started post-graduate training, I'd seen the basics at least twice. This unique phenomenon of medical training conditioned me to stop asking questions and to start feeling like I knew something because maybe I should already know it.

"Pimping" is the term used in medicine to describe a more experienced doctor putting a less experienced doctor or medical student on the spot and grilling her with questions. You are expected to know the answers. More than once I have put on a practiced look of concentration - scrunching up my eyes, pursing my lips, and staring off into space -while mumbling, "I remember reading about that last night in Harrison's. What did it say ..." while everyone around me looked on with expectant eyes, some having no better idea how to answer the question than I. For me, firing back the correct response was expected, but still won me the internal right to step solidly through hospital corridors, my long white coat flowing behind me, secure in my knowledge and abilities as a doctor.

As a doctor, it was difficult to say I didn't know the answer. I would hesitate to ask a question about something I didn't understand because I often felt I was going to look incompetent, stupid, or both.

I think it's something about the highly selective process involved in getting accepted to medical school; most people know someone who had dreams of becoming a doctor but couldn't get into or finish medical school. The high volume of reading and memorization required, coupled with the enormous mental and financial burden along the way, can condition someone to think they have to play the know-it-all. God forbid all this work and money are for nothing. Public expectations of perfection and fear surrounding the uncertainty of illness also contribute to physician expectations of themselves and their peers.

THE LIMITS

I've found something interesting as I continue to plow through my graduate school classes. A doctor's knowledge and learning style only gets me so far in the world beyond clinical patient care and medical expertise. I don't always grasp new knowledge and concepts easily. It scares me a lot. I know school. I know how to pay attention and how to read the book to find any information I might need, but I don't know what a business plan entails. What is GAAP and how does it relate to accounting? I didn't know what the Hill Burton Act did for hospitals. I didn't know some of the important concepts of the 1985 legislature of COBRA, the 1982 legislation instating DRGs or what the HIPAA act was really trying to accomplish. I had no idea how to apply pro-market and regulatory approaches to healthcare and back up my arguments. I recently ran across an article in the Journal of the American College of Surgery about surgeons writing up a business plan with no prior experience. So it's not just me. But I am still sometimes tempted to nod my head and smile, pretending that I do understand. I try to stop myself. It takes a real effort to say, "No, I still don't get that. I didn't understand it the first time you explained it to me." I feel people expect me to quickly understand; I expect the same thing of myself.

But I'm starting to understand I'm not expected to know all the answers yet. It's not a bad thing if I need extra explanations or another example to get the concept. My peers and my professors haven't viewed me negatively. It's a new way of learning for me and it's hard, but it's definitely one of the reasons I wanted to go back to school, and I'm getting better at thinking in this new way.

I already have another idea for the essay contest.

Michelle Mudge-Riley, DO, is currently a student in the Masters of Health Administration program at Virginia Commonwealth University in Richmond. She graduated from Des Moines University Osteopathic Medical School in 2003. She can be reached at mudgeriley@yahoo.com or via editor@physicianspractice.com.

This article originally appeared in the March 2006 issue of Physicians Practice.