I ended my last post saying I was going to follow-up with residents’ perceptions of score versus comments on ITERs, but I’m taking the blogger’s prerogative and putting that on the back burner until next time. That’s because I was reminded about the importance of something else recently. The importance of saying, “I don’t know”.
I was recently invited to co-facilitate a session at the Canadian Internal Medicine Chief Resident Conference. Six of us were asked to lead small group discussions about “How to Give a Good Morning Report.” Morning report is the traditional teaching session that occurs in most internal medicine programs during which time students, residents, and faculty participate in a group discussion about a clinical case (or several). Usually these discussions are facilitated by a staff physician or a senior resident, commonly the chief. Many other specialties also have variations on this type of teaching in their programs.
Four our session, we had an outline of things that we wanted to cover. However, what really dominated the discussion, at least in my group, was how to manage the situation in which you feel like you have insufficient knowledge or are out of your clinical depth as a teacher. I thought there would be more conversation about eliciting input from a quite audience or managing overly enthusiastic elective clerks (and there certainly was some of this), but what was really striking was the trepidation about managing a “cold case” without being adequately prepared for the content and questions that might arise.
As physicians, we aim for perfection. We want to have all the answers. All the time. Especially standing at the front of a room full of more junior learners. But that’s not real life. Every day, we see patients that give us cause to look up something or consult a colleague. This uncertainty and life-long learning needs to be built into, and even explicitly role-modelled in teaching. Not only is it not feasible nor realistic to be prepared for every clinical teaching session, it frankly looks pretty fake when it’s attempted. Sure, every medical resident should have the management of common life threatening problems like seizures and hyperkalemia at their fingertips (which no chief resident would need to prepare in advance), but the diagnostic criteria for rare diseases can (and should) be looked-up rather than portrayed as something that people should just know.
Often, one of the most powerful teaching points that can be made during clinical teaching is to say, “I don’t know.” Not only will it make people appreciate you for your honesty; but it also permits the more junior learner to feel less anxious and less alone. It demonstrates that we all have limits to our knowledge and that we need to be continuously learning. It may also let someone else in the session feel good about him or herself if they happen to know the answer (public acknowledgment does wonders for the esteem of learners). Let’s remind new teachers and ourselves that saying “I don’t know” is valuable lesson to role model and not an admission of weakness.
I completely agree with the expressed sentiments. I often use the “I don’t know” role modelling technique (mainly because there are so many things I don’t know). I teach my learners to be “confidently unsure”. ie how to say you have no idea in a confidence inspiring way. And follow that up with how you’re going to find out. eg. That’s a really interesting rash. I’ve not seen one quite like that before but I’m going to consult a colleague and we’ll get to the bottom of it.” In real life (unlike in most exams), what you “know” matters far less than knowing how to find out (appropriately and efficiently).