What kind of topic is “Why we need more not knowing in medicine?” Many people might call it illogical, even frightening. Patients, families, and society expect physicians to have answers. But is knowledge enough?
After I completed medical school and my emergency medicine training, I possessed a solid bank of medical knowledge. There was only one problem. My patients’ symptoms were not test questions in human form. The answer wasn’t always A, B, C, or D. Rather, my patients resembled fascinating characters in complicated stories, struggling to cope with betraying bodies, insidious diseases, lousy luck, and a tomorrow where the landscape is ever-shifting.
Their chief complaint wasn’t the first piece of a puzzle but the first line of a story. Stories that were rife with uncertainty and gaps, where important details were buried in the silences.
I’d find myself frustrated, which often morphed into anxiety, self-doubt and a whiff of disillusionment. And if I was tired, hungry, or having a bad day, this frustration sometimes bled into my behavior with patients.
It soon became clear was that not all these patients expected an answer. But they insisted on and deserved a meaningful response.
How did I become comfortable with uncertainty in medicine?
Creative writing skills, elements of craft indispensable to building narratives from the ground up, were essential to understanding the stories of my patients.
Physicians, and all healthcare providers are fundamentally professional story-listeners, story-shapers, and story-responders. This shouldn’t come as a surprise; people have understood each other and the world through the telling, listening, and interpreting of stories.
But increasingly complex health problems compounded by other struggles including socioeconomic troubles, substance abuse, mental health, homelessness, and threadbare social fabric make for increasingly complex stories.
Healthcare professionals make decisions, including the appropriate use of technology, based on the stories patients share.
Health providers must think more creatively, like creative writers. In the narrative disaster zone of the emergency department, patients’ stories often feel like first drafts, and first drafts—for most of us—can be raw and messy.
When faced with challenging stories, decision making requires medical knowledge as well as the ability to ask the right questions. We must do everything in our power to ensure the story we are hearing is the one our patients are trying to tell.
In many ways, doctors are makers, just as creative artists, and “Not Knowing” is crucial to art.
In his essay “Not Knowing,” the writer Donald Barthelme said that writing is a “process of dealing with not-knowing, a forcing of what and how.” Barthelme doesn’t problematize problems. In fact, he states that the more serious the artist, the more problems the artist take into account. By favoring easy problems or more comfortable language, we evade our responsibility to question, to probe and to challenge the messiness that others might otherwise encounter and accept without deeper examination.
Unjustly minimizing messiness has consequences for patient care.
We need more not-knowing in medicine because physicians and all clinicians must learn to embrace problems, consider problems and constraints as opportunities. Physicians have much to learn from experts in uncertainty and not-knowing–artists, writers, designers, and humanities scholars.
Our patients need creative physicians who are science-using and story-minded, who know the critical function of stories and how they impact how we understand and ultimately respond to them. Expertise in story is a low tech skill that’s fundamental to connection, communication, curiosity patient-engagement and problem-solving. The best medicine doesn’t work on the wrong story.
Watch the full FIX18 talk below!
A truly excellent, thoughtful and very relevant approach.