The doctor who doesn’t know

Given the complexity of medical knowledge and the fear of disease, the ‘all knowing doctor' approach is understandable. However, a cocksure doctor doling out instant advice with an air of finality may be more optics than substance. A doctor who knows that he doesn’t know and is willing to admit it, may be acting in your best interest.

Sanjay Nagral
Aug 28, 2020, Mumbai Mirror

I had just entered the world of private practice. A patient with a rare surgical disorder came for an opinion. He was accompanied by his family doctor, a renowned senior. After listening to the patient and going through the large number of investigations, I wasn’t sure what to advise. I opened the computer in front of me to check on the current treatment options and their effectiveness. I then requested time to seek opinions. The same night I got a call from the family physician. “You are young. Can I give you some advice for your career?” he asked, sounding rather paternalistic. “I think you shouldn’t have opened the computer. It doesn’t suit a specialist doctor like you. He may feel you don’t know your subject,” he said. A bit stunned, I responded with a polite ‘thank you’. Needless to say, the patient did not come back to me.

Doctors in India are supposed to be all-knowing. Or at least they try to fit that image. This has been normalised by everyone, including patients. As a medical student, there is a message passed down that a doctor must exude confidence and finality. This behaviour is even supposed to be therapeutic to patients. Would you like your doctor to say ‘I am not sure’, ‘let me check it out’, or even worse ‘I don’t know’?

Medical knowledge is growing exponentially. It is impossible for a doctor to know everything even about his or her speciality, leave alone other fields. So, when faced with difficult problems, one can go along with old knowledge, experience or intuition. This may work. However, treatment options evolve, old ones are discarded, safer and more effective ones are introduced with astonishing frequency. Of course, everything new is not necessarily good. But knowing the limitations of one’s knowledge and willingness to check out the current trends helps to offer the right therapy.

High quality, updated and reliable information is now available with ease on a smartphone. Whether it is treatment guidelines, drug dosages, interactions or side effects, it’s all there in reliable resources. It is routine in some countries to see doctors and nurses carry iPads in hospitals and refer to information. It’s not looked at as an embarrassment. A study from the US shows that the use of a well-known database resulted in reduced deaths in hospitals that used it as opposed to those that didn’t. Some of these are due to reduction in medication errors.

With healthcare in India otherwise claiming to be ‘world-class’, accessing updated information at point of care as aguide to everyday practice is rare. With everyone carrying smartphones, a lack of access cannot be the reason. One embarrassing reason is that we are largely unaccountable for errors; and get away with them.

We have no inbuilt mechanism to counter check drug dosages, though a smart chemist sometimes does that. Very few hospitals have clinical pharmacologists to do that. This can have serious consequences. Wrong dosage and side effects can be potentially fatal. They can lead to a lack of response to treatment due to underdosing, wellknown with TB medication. And use of drugs that have been withdrawn from the global market due to adverse reactions.

A significant part of new knowledge for doctors comes from pharma representatives or sponsored education. This is inherently biased information. No wonder, many drugs and combinations which are absent from standard drug formularies are freely prescribed in India. The reluctance to check independent evidence helps the pharma industry market irrational drugs. Pharma insiders proudly say they can get doctors to prescribe anything.

In April, I wrote a piece in this column titled ‘Should I or should I not?’, where I dwelt on my confusion about consuming hydroxychloroquine since I had contact with Covid patients. I got feedback that rather than clearing doubts I was adding to confusion. However, the liberal prescriptions of hundreds of unproven drugs in Covid is not aresult of clarity. How can a doctor not prescribe anything or Covid?

It is impossible today for a doctor and apatient to agree to ‘no treatment’ as a treatment strategy. There are several situations where this is actually the best approach. A famous old surgical strategy called ‘masterly inactivity’ in which you closely observe a patient but don’t intervene is still popular. Which is what 90% of Covid patients need. Covid demands the ability to say ‘we don’t know for now’ as never before.

In many cultures, the image of doctors as the all-knowing experts has provided comfort to a population that therefore surrenders to them. Given the complexity of medical knowledge and the fear of disease, this approach is understandable. However, a cocksure doctor doling out instant advice with an air of finality may be more optics than substance. A doctor who knows that he doesn’t know and is willing to admit it, may be acting in your best interest.