Mine was an unusually long hiatus from residency for research training. And in the rough readjustment to clinical environments and work processes, one forgotten element seemed glaringly problematic: “Have a plan,” said one attending, “If you don’t know, just guess.” And another, in a teaching session, “Just guess, even if you’re wrong.” From a chief resident during an awkward pause when a junior was put on the spot: “Just guess; it’s OK.” When someone dares to ask a senior about the next step planned for a patient, the response often is “You tell me” or “What do you think?” In other words: If you don’t know — guess. Of course the intention has merit. But for being the behaviors we are inculcated with during our formative years, I think there are dangerous consequences. We now hear that medical errors are the third leading cause of death, it takes decades for evidence-based practices to be implemented, there are huge health care quality disparities within our country and pressure for performance is contributing to physician burnout and suicide. Is any of this really a shock? Surely, our knowledge base is to grow through training, but with it, we are to foster the habit of confident guessing in how to manage patients. We are to overcome the natural fear of being wrong when learning material about decisions that affect people’s lives. I’d posit that this doubt, given the stakes, is one that should be cultivated, not conquered. Training is to develop a reliance on our own memories and judgments, rather than acquiring skills in using systems to ensure correctness so that error is avoided. We are steeped in practices of no antecedent correctness and inconsistent subsequent correction. Allowing wrongness through guesses is the standard way of teaching on wards, likely to the point that when fully trained we are unable to distinguish knowledge from guessing and judgment calls. Even in the ubiquitous multiple-choice test throughout schooling, the paradigm is clear: if you don’t know, just guess, as one incorrect answer won’t hurt you as much as cheating would. The exact opposite is true for real patients. Is the toll of medical error really a surprise? In 1927, William Mayo criticized medical educators for demanding students remember information that “all can be obtained from books,” when instead, “We should teach [them] how to think and where to look for information.” The late Larry Weed, father of the problem-oriented medical record, has called for change in training and practice for decades. He states, “Medical schools give students a misplaced faith in the completeness and accuracy of their own personal store of medical knowledge and the efficacy of their intellects,” while calling for a paradigm of medicine in which “knowledge is in tools instead of heads.” He called medical education the greatest barrier to widespread health care reform, that students should “access and apply medical knowledge rather than learn it.” We need to formulate a new way of practicing medicine, starting from training, that forbids guessing and error by allowing and even requiring dependence on external tools for helping with forming management plans. There easily could be usable, standard resources and systems for at the point of care that are reliably updated with current recommendations, so we can replace “just guess, even if you’re wrong” with “just check, even if you’re sure.” We have seen the success of surgical safety checklists, one of the few widely implemented structures that relieved practitioners of the misconception that smart, hardworking, compassionate doctors always will know or think of everything that needs to be thought of. All clinical processes — from interviewing to the formation of any diagnostic or treatment plan — also need such external assistance, regardless of whether or not doctors think they need it. I’d like to call on governing boards of medical education and licensure to reassess training and competency paradigms and reevaluate what role doctors’ memories should play in future medicine, especially knowing recommended practices can change at any moment as cumulative medical knowledge grows at an ever-increasing pace. Modularize testing so we can focus our efforts of memorization on management of emergencies, anatomy, and procedures. Anything else should allow use of resources, possibly testing comprehension — but not recall — of other topics. It has largely been thought that if you’re smart enough, work hard enough and care enough, you shouldn’t need assistance in forming clinical management plans. But we all know that paper and computers can store information better than our heads can. Let’s relinquish the notion that our intellects are defined by how well we can match paper in information storage abilities, but relish how brilliantly the human brain evolved to have refined more complex functions than those so easily relegated to nonliving entities. We can welcome the assistance such things can offer us and embrace their partnership with us in our mission of healing. I do not want to be the kind of physician our training is molding us to become: one who regards my own unaided memory as reliable, sufficient and current for my patients’ needs. Our goal is to learn how to doctor without peeking, errors allowed; I want to doctor without errors, peeking allowed to offer my patients more than only what I might happen to remember at any given time. I want all patients seen by any of my colleagues above or below me in the memorization-and-recall competitions of training also to be offered more — the relevant collective whole of cumulative medical knowledge. When patients come to me as their doctor, please don’t let me guess and be wrong. Please have us all use assistance and be right — the first time, every time, anytime. Traditional academic integrity and primum non nocere (first do no harm) are contradictory principles in medicine. I want to choose primum non nocere. Welcoming assistance is the smart thing to do, and even more than that — it’s the right thing to do. Source
