Clinical Humility and the Limits of Medical Knowledge

A friend of mine has thyroid cancer. He went to three specialists when he received his diagnosis. The first recommended a full thyroidectomy to remove the entire tumor. The second recommended a series of two smaller operations to remove the tumor rather than a single surgery. The third recommended chemotherapy followed by two smaller operations, but not removal of the entire tumor, which he felt could result in my friend losing his voice.

All three seemed confident in their prognosis. Not one uttered the words, “I don’t know.”

One of the greatest challenges in medicine is the desire for clinical certainty. Our patients demand it. Our colleagues demand it. Many physicians, determined to offer their patients certainty, shy away from admitting that all too often they cannot offer assurance. Yet anyone who practices medicine knows that “it depends” is often the most accurate answer we can give. This problem was on prominent display during the COVID-19 pandemic, when many experts responded to this time of grave ambiguity by offering well-intentioned but misguided certainty. Rather than creating a sense of calm, they contributed to an erosion of trust in health care and public health when facts and circumstances changed quickly.

As I’ve reflected on how clinicians responded to the COVID crisis, I’ve come to believe that being comfortable with saying “I don’t know” is one of the most important ways we can build trust with our patients and one another. All of the physicians my friend saw are excellent practitioners who are committed to helping him. But they, like so many doctors, have likely been trained to perpetuate the myth of the all-knowing healer. I believe medical education must do more to explode this myth so that we can serve our patients more effectively.

When I was at Harvard Medical School in the early 2000s, Daniel Lowenstein, MD ’83 — then the dean for medical education — introduced a new curriculum that emphasized what I’ve come to think of as clinical humility. In the 1980s and 1990s, physicians were trained to project total confidence in their vast medical knowledge, but people like Dr. Lowenstein argued for a different approach. Today, mastery does not mean knowing a lot of information; it means synthesizing information. Board exams and certifications are now open-book exercises, and the growth of e-consults among clinicians signals a willingness to ask questions.

I’ve found that this sort of humility is a great trust-building managerial skill outside of clinical settings. But despite changes over the years, I still find such an approach rare in medicine. To help me think about why that is, I reached out to a handful of my fellow HMS alumni to gauge their experiences with what I call “clinical humility.” Their thoughts, I believe, offer a great starting point for what I hope will become a broader conversation on this topic.

Ruma Rajbhandari, MD ’07, HMS assistant professor of medicine at Massachusetts General Hospital and a gastroenterologist, wishes that clinical humility had been a more prevalent element of her medical school training. “You only start seeing it and learning it once you practice,” she told me. “The focus in med school was coming to the right diagnosis and having an answer.” There are a lot of gray areas where you can’t follow the book, she added. “I think the good clinicians are the ones who are apt to say, ‘I don’t know,’ and patients appreciate that.”

For instance, Rajbhandari said, she recently served as the third clinical option for a patient who was experiencing abdominal pain but whose workup suggested no clear source of the pain. Rajbhandari acknowledged that no test or procedure had yielded solid clues and then turned the conversation to how best to manage the patient’s symptoms.

“It happens all the time, because we don’t have the answers for everything,” she said.

Thomas Kozhimannil, MD ’06, an anesthesiologist in Minneapolis, said he doesn’t recall having discussed at HMS the importance of acknowledging uncertainty with patients. But he had some ideas about how to incorporate it into a curriculum, including as part of the observed structured clinical examination, or OSCE.

“It could be a really salient part of the OSCE to have an exercise with patient-actors and talk about a clinical situation where there’s some uncertainty,” he said. “Real clinical medicine has lots of gray areas that are far removed from the neat, obvious situations that are often put forward in medical school.” He thinks that when clinicians deliberately discuss their uncertainty about clinical decisions with patients they may open up deeper conversations that better enable shared decision-making.

“Patients appreciate when physicians are candid,” he said, “even if it means not everything is known about the situation.”

Conor Kleweno, MD ’07, an associate professor and orthopedic surgeon at the University of Washington, agreed that acknowledging uncertainty is arguably most useful as a starting point in a conversation.

“Saying ‘I don’t know’ is important, but more important is putting it into context for the patient,” Kleweno said. “For example, a patient might ask, ‘Is surgical option number 1 or number 2 better?’ If I only say, ‘I don’t know,’ then that’s not helpful.” In this situation, he said, it would be more helpful to reframe the question to discuss why a person might choose one option rather than the other.

“Providing the context of the uncertainty is essentially answering the question they’re intending to ask,” he said, adding that sometimes what the patient wants to know is what the clinician would recommend, given what the patient has told the clinician about their values and goals.

“The paradox here is that as an experienced clinician, we almost always do ‘know,’ within the framework of variance and confidence intervals,” Kleweno said. “But obviously we almost never ‘know’ in terms of predicting the future.”

Nancy Oriol, MD ’79, HMS faculty associate dean for community engagement in medical education and an anesthesiologist, said not all patients will benefit from full clinical candor from a doctor.

“One patient may want the doctor to say, ‘I’m going to lay my hands on you and you’re cured.’ Another wants the doctor to hear their perspective and be equal partners in the decision-making,” she said. “So the most important skill is the ability to listen, and then modulate how you talk to fit the patient’s needs.”

Oriol said this approach is consistent with Francis Peabody's famous dictum, “the secret of the care of the patient is in caring for the patient.”

“The question is, what do you consider caring?” Oriol said. There are times as a patient where I just don’t want to hear the doctor’s internal dialogue, and then there are other times where I want to talk about the mystery. It comes down to the ability to listen for what the patient needs in that moment and deliver that in a way that doesn’t compromise the truth.”

After these discussions, I’ve come to believe more strongly than ever that it’s time to retire the concept that physicians have all the answers. In sum, my peers’ responses demonstrate that this attitude puts the focus of treatment on physicians, when it really should be on our patients. Yes, our duty is to heal our patients. But it’s also to help them understand the limits of medicine, so that together we can make decisions that meet their needs and goals.

Sachin H. Jain, MD ’08, is president and CEO of SCAN Group and Health Plan, an adjunct professor of medicine at Stanford University School of Medicine, and a contributor to Forbes.

Image courtesy of Sachin Jain