On the small island where I live there is a doctor people speak about fondly and a doctor they do not.  The loved doctor’s kindness, sacrifice, and willingness to tell patients when their problems are beyond her expertise are universally praised.  When they speak of the other doctor they shake their heads, roll their eyes and say he’s likely to make a joke of their concerns.

I’ve met this second doctor.  He is relatively young and has a friendly, open face.  He makes jokes and moves confidently around his patients with a casualness meant to be disarming.  There is something resigned about his demeanor too-the way he falls into a chair and sighs as he writes a prescription, or how he leans against the exam room counter top as if he would fall over without it.  I do not think he is a bad doctor.  In fact I think he is more than competent.  But he is also significantly overworked on an island that does not have enough people for the government-run clinic to justify spending the money to build and staff a true hospital with well equipped emergency services.  Instead he has to make due with limited staff and equipment while still trying to treat the entire spectrum of medical problems-from simple colds to life-threatening traumas- anytime of the day or night.  This impossible situation is enough to wear the best physician down.

But the loved doctor, who shares his burden 50/50, is not perceived as arrogant or belittling.  What makes the difference?  Some of it is just intrinsic personality differences and the ways two unique people cope with stress.  After all, doctors are not automatons.  I think there is something else though, something that makes a bigger difference in their perceived styles.  And to explain it I have to go back to my own experience of becoming a doctor.

I never intended to go to medical school.  I majored in biochemistry because I loved the subject and I loved my other required classes such as organic and physical chemistry.  The pre-med students in my classes seemed only interested in their grade point averages.  I looked at them derisively as they tried to wheedle upcoming test answers from our professors.  Having the right answers was more important to them than actually learning.  Because of this I vowed never to consider becoming a doctor.

That lasted two years.  Through an unexpected series of adventures I found myself in medical school surrounded by the same people I thought myself so superior to.  Luckily I found out how presumptuous I’d been and how good a group of people they were.  But one thing was the same.  Having the right answer remained supreme.

Really this should not be surprising.  Since elementary school we are judged on whether we have the right answers.  If we do we are rewarded with good grades and move onto colleges and universities where we are still tested in an increasingly competitive environment on whether we know the right answers.  Four more years of right answers later, 16 years of acculturation in what determines a smart, capable person behind us, we are worthy to go on to medical school.  And in this most competitive of environments, where students and later residents are vying for a tightly controlled number of specialty training spots, what is judged and valued, you guessed it, are right answers.  There is even a term for being peppered with questions by an attending doctor-being pimped– as if a student’s mind is a prostitute required to perform.  If you don’t have the right answer you are harshly judged and often ridiculed.  One time during residency, after answering a question too vaguely, my chief resident snapped, “That’s a first year medical student answer,” with a disdain meant to deeply humiliate.  The amount of hate he conjured in his face and voice was extraordinary.

In this setting honesty cannot triumph.  I have watched my fellow students and residents blatantly lie about exam findings, patient histories, or even test results to cover up things they did not know.  And this all-consuming pressure to be right does not end with training.  Teachers and Attendings are replaced by colleagues and patients.  The expectation that doctors know everything and are always right is a double-edged sword.  It not only prevents the doctor from being truthful about their limitations, it also colors the way society perceives doctors.  We’ve been promoting our intellectual invincibility for so long it can be very distressing for a patient to hear a doctor admit ignorance.

But here is the dirty secret of medicine.  We don’t know.  This is too simplistic, I know, but there is a lot of truth to it.  New studies come out all the time refuting previous studies that were the cornerstones of medical care.  We see it in the continual pendulum swing of dietary recommendations, recommendations for treating blood pressure, antibiotic usage, etc.  We are still stumbling around in the dark, waiting to see if the treatment du jour will turn out to have significantly negative side effects in 10-15 years.  Treatments that were the cutting edge of their time are barbaric by today’s standards (i.e. lobotomies) and cutting edge treatments of today will be considered barbaric in 50 years.  The sooner we embrace the uncertainties of medicine, like the uncertainties of life, the sooner we can shed our need to be right and start having more honest discussions with our patients.  It will take some time to shift society’s expectations, but slowly we can turn our patients’ need to have the right answer to a deep, comforting trust in our care.

I think this comforting trust makes the difference between the loved doctor on my island and the other.  She takes the time to listen to patients, carefully examines them, and afterward can still throw up her hands and admit ignorance.  Even if she comes up with less answers than her colleague, her patients appreciate her for her honesty and caring and trust her more than a doctor who cannot admit what he doesn’t know.