Thursday, 21 Sep 2017

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What You Don't Know

“It’s unbelievable how much you don’t know about the game you’ve been playing all your life.”
- Mickey Mantle

Baseball icon and Hall of Famer Mickey Mantle had an aw-shucks, Oklahoman wisdom that added to his immense popularity. Being both humble and confident, his quote contrasts his many successes and achievements in baseball. Was it that he did not have enough time to know it all or is he referring to the enormity of the sport and career that he only mastered 30% of the time (lifetime batting average = 0.298)?

What I know and learned is often the subject of blogs on RheumNow. Yet, I’ve always been challenged and irked by what I don’t know.

The quote, “you don’t know what you don’t know” has uncertain origins, but was memorably used by the US Secretary of Defense, Donald Rumsfeld, during a 2002 speech:

“Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don't know we don't know. And if one looks throughout the history of our country and other free countries, it is the latter category that tend to be the difficult ones.”

You may consider the unknown unknowns to be confusing, ambiguous, or poor grammar, but it does describe a thankfully small subset of clinical scenarios which do tend to be “the difficult ones”. It is an important, if not perplexing, slice in the pie of life.

It's great to be encouraged by what you know and learn daily. But surely you’ve been humbled, frustrated or shrugged off what you don’t know.

  • The patient who is later is still immobile and in pain, despite their joint replacement 6 months ago. (it wasn’t bone-on-bone pain, but must’ve been from causes not addressed by surgery)
  • The new, seropositive, classic RA who fails to respond to methotrexate and 2 different biologics (does she just need the right 3rd biologic or is this arthropathy in this patient not easily understood?)
  • Palpable synovitis that’s not tender (just how does that happen?)
  • The gout “attack” that persists for weeks and doesn’t quite respond to your best prescriptions. (may be what’s been taught about the chronology of gout attacks wasn’t so right; or maybe the diagnosis needs to be re-thought?)
  • The clinical trial that yields an expected 60-40-20 ACR response but inexplicably has a 40+% placebo response or no X-ray progression in any of the treated groups. (here we can only blame the randomness of patient recruitment and in this case they were the wrongly chosen or inexplicably aberrant)
  • You don’t know the answer to the question the patient has yet to ask. (Corrollary: you don’t know what the patient will say if they kept talking)
  • Patients don’t like the unknowns that underlie their complaints – that’s why they seek you out.
  • You don’t know the diagnosis until too late, when the damage is done and the process is not reversible. (the dictum “diagnose early and treat aggressively” enhances the odds of avoiding this circumstance)
  • Heck, you don’t know when your first patient will arrive and your last patient will check-out. (Hence there’s great safety in arriving early and planning to leave late)

I guess the question is - is it worth the worry? Do you need to make allowances and margins that protect you from the unknowns?

What is your plan or approach for identifying what you don’t know or how you will recognize the unknowns unbeknownst to you?

I believe most of us shake off and leave behind these obtunded events like a batter shakes off a strike out and looks forward to the next at bat.

But what if I keep striking out? Shouldn’t I learn from this event or better prepare for the next time? I think it’s a tall task to develop insightful recognition and an approach to uncertainty. Wouldn't you agree that our commitments to the primacy of patient welfare and the dictates of professionalism require our ongoing competence and the acquisition of medical knowledge.

Remember the line about the best surgeon being the one who knows when not to cut (as opposed to “a chance to cut is a chance to cure”)? The same goes for the lawyer who doesn’t and shouldn’t ask the question he does not know the answer to. It's great to live with certainty. Wouldn’t it be even greater to know how to tackle uncertainty.

Uncertainty does not mean risk (http://buff.ly/2mKi2qt). Uncertainty is where you are when dealing with unknowns. Uncertainty often yields unexpected or new outcomes that challenge your world of knowns.

The best rheumatologist is the one who knows when:

  • NOT to prescribe an NSAID, steroid or biologic
  • To get the biopsy and not rely on the lab test alone
  • Refer to physical therapy before doing surgery
  • When to run a case by your colleague(s)
  • When to go with whats popular/marketed or handy and when to stop, read and research

So how should deal with uncertainty or worse yet, the unknowns you’re unaware of. These are my best suggestions. Might you have a few of your own?

  1. Commit to a plan for learning. It started in med school, was refocused in fellowship and will continue for those of you who have adopted a process, plan or curriculum for future learning.
  2. Consider one big learning event per year (e.g., ACR annual meeting) and multiple small or ongoing learning forums every day, week or month.
  3. Integrate and involve others. Participation in shared educational activities is highly effective and easily expands your knowledge and management repertoire.
  4. Frequently revisit and reexamine the dictums and standards you have been taught. For instance, based on what I’ve relearned at ACR 2016, the use of “stress dose” steroids is unnecessary and should be replaced by continuation of the same stable daily dosage.
  5. Focus on the problem – not collateral issues. Approach the problem from multiple angles. Step away and get a different perspective. Get input from all the stakeholders. Ask all the questions – Who, What, Why, How, When and What-tha’?
  6. Focus on what you can control. What you cannot should be referred to another or managed in an alternative (e.g., team approach) manner.
  7. Clarity for managing uncertainty comes from taking stock of what you know and what you don’t know, and then assigning the degree of importance to both. This often makes clear what your next steps are and when to abandon or relentlessly pursue solutions (http://buff.ly/2lYRUtF).
  8. Good enough. In life and practice we often strive for perfection, but in doing so perfection becomes the enemy of good. Know when to say I/We did “good” and “enough”.
  9. It may be better to have no diagnosis instead of the wrong diagnosis. Often its best to have an unknown diagnosis (incomplete syndrome or unestablished disease) than the known diagnosis (i.e., Lupus) ; as the latter comes with a full complement of criteria and manifestations that the patient would not want. Time provides some of our best answers.
  10. Coaches use to teach us “luck is when preparation meets opportunity”. Applied to your current life and practice, I’m suggesting it’s ok to “trust your instincts”. We all prefer sure-fire solutions, but at times, it’s ok to go with instinct when the available evidence doesn’t fit the questions or scenarios in front of you.


"About the only problem with success is that it does not teach you how to deal with failure." - Tommy Lasorda

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He is the Executive Editor of RheumNow.com and Co-Editor of the online textbook RheumaKnowledgy.com. Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Great thoughts! I have learned that sometimes "less is more" in regards to prescriptions and procedures. Uncertainty is a part of rheumatology that most patients have difficulty accepting. While "no diagnosis" is a disappointment to all involved, I remind the patient that "no diagnosis is better than the wrong diagnosis!" We all must stay alert and vigilant until matters come into focus. Sometimes a condition a patient does NOT have is more comforting to them than a diagnosis (hopefully correct) of a condition they do have which does not lend itself to the medical model. Sometimes all we can do is validate rather than reinforce the patient's response to their predicament. -D,Knapp
David, the sage rheumatologist takes his time, especially with uncertainty, knowing that time provides some of our best answers. I agree with your points about no diagnosis vs wrong diagnosis. I would add its often better to have the unknown diagnosis than the known diagnosis; as the latter comes with a full complement of criteria and manifestations that the patient would not want. Good comments! JC
Quite thought provoking. Reminds me of an old saying- "everyday there is a new question AND that is what keeps us going" Nobody can know everything. Being in the realm of uncertainty certainly keeps the doors of new learning open.
Parshant, I like how you can make uncertainty a motivation. A funny (but true) line from the "Car Talk" radio show comes from Tom Magliozzi who said "the great thing about being stupid is you learn something new every day!"