You Want A Humble Physician

 

Photo by Paul Gilmore on Unsplash

While reading this article the other day, I came upon a quote from Dr. Mike Tuttle, one of the best thyroid cancer specialists in the United States:

I would not have guessed that would happen in a million years.

He was speaking in reference to a study in which he and his colleagues monitored patients with known thyroid cancer using serial ultrasounds, as opposed to sending them directly to surgery.  This is an area of increasing interest among thyroid cancer specialists like myself, because we recognize that many of the small thyroid cancers we diagnose would never have spread or caused any major problems, even if not removed.  Unfortunately, we don’t yet have a way of predicting which patients have tumors that will behave lethargically and can be watched, vs. which patients have tumors with more aggressive potential that need to come out.

When asked about the finding that 19 patients saw their cancers shrink by at least half over the course of the study, Dr. Tuttle admitted what I’ve quoted above.  Now, I sort of know Dr. Tuttle.  Not on a personal level, mind you.  But I have attended at least 10-15 of his lectures over the years at our major Endocrinology meetings.  I have also emailed him about one or two of my toughest cases, and he has been kind enough to offer counsel.

I can say – without overstatement – that he is one of the most thoughtful physicians I’ve ever known.  I don’t mean thoughtful in the sense of being considerate, though I expect he is that, too.  What I’m saying is that he gives off an aura of carefully thinking through clinical conundrums, taking all the evidence to date into account, and then reaches a decision that sounds incredibly reasonable.

To give a little more context before I get to my point, Dr. Tuttle is akin to royalty in the Kingdom of Endocrinology.  His lectures typically play to a packed house, often with people standing in the back and along the sides of the room.  Part of this is due to his speaking style, which is laugh-out-loud hilarious.  Funny probably isn’t the first word that comes to mind when contemplating thyroid cancer, but he somehow makes it work.  The other reason for his popularity is that doctors know they are guaranteed to learn something new that will be immediately applicable to how they practice.  The guy is so sought after that the line to speak with him after a lecture can be tremendous.

You would think that, with all these people hanging on his every word, Dr. Tuttle would have cultivated an attitude of superiority by now.  After all, I’ve met many high-powered Endocrinologists over the years, and a fair number of them regarded me like the nobody I am (seriously, I am nobody when you consider the who’s who of Endocrinology on a national level).  But Dr. Tuttle isn’t like that, and I think I know why.

The longer you practice, the more you realize you don’t know.

This may sound counterintuitive at first blush, but hear me out.  While training in our specialties, as physicians, we are appropriately unsure of ourselves.  The ones who don’t obsess over whether they are making good decisions scare the heck out of me, frankly.  At some point during training, however, there comes a time when we start to think, “I got this.”  Then, most of us leave the nest to go into private practice (some stay in academic medicine), and all of a sudden, there is no longer a mentor looking over our shoulder.  The best doctors (in my opinion) regress a little at this point, again obsessing over the soundness of their decisions.  Eventually, as time passes, we gain confidence and re-embrace the “I got this” mentality.

Unfortunately, believing too strongly in our competence is the very thing that impedes our metamorphosis from good clinicians into great clinicians.  I tend to see this play out in some early career subspecialists, who tend to be very “certain.”  They are certain they know what the patient has, certain they know the best and only way to treat it, and certain that anyone who says different is wrong.  As an aside, these are also the folks who seem to feel overly self-satisfied when they dismantle the naturopath’s treatment plan (you know I’m not complaining about that), but they don’t offer the patient an acceptable alternative to the quack’s advice, basically saying “It’s my way or the highway.”

Getting back to the issue of “certainty,” older clinicians will tell you that certainty is a squishy thing.  As a mid-career Endocrinologist, I’ve seen rare presentations of common diseases, in which I suspect a less-seasoned doctor might have thought, “No way can this be that.”  I’ve seen clinical practice guidelines for the surgical management of thyroid cancer change to the point of tossing out years of dogma, then change back (a bit of an oversimplification, but I’m trying to make a point).  I’ve seen Endocrinologists prescribe T3 like water, then tell everyone they need to get off T3, and now revert to cautiously trying small doses of T3 in selected patients.

The point is, if we’re really paying attention, we should realize that much of what we “know” today may be different in 5 or 10 years.  Internalizing that concept should cultivate a sense of humility, no matter how high you reside on the totem pole.  So, when I see a physician of Dr. Tuttle’s caliber say, “I would not have guessed that would happen in a million years,” my first thought is not, “Gee, that guy’s supposed to be the expert?”  Rather, it’s “I want that guy to be my doctor when I get sick.”

 

What do you think?  Are your doctors humble or cocky?  If you’re a physician, where do you see yourself on the spectrum between humble and cocky?

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4 Replies to “You Want A Humble Physician”

  1. I had a very cocky pelvic surgeon insist that her surgery had completely rid my body of endometriosis and if I was still having cyclical pain, I needed to go on birth control or get pregnant. She dismissed me from her practice when I started asking for alternatives (like PT or topical pain meds), saying I was cured and needed to talk about other issues with my regular ob. I’ve found a handful of online reviews with similar stories. I’ve been very careful about choosing humbler doctors since.

  2. Great points. We are human, We grow and change as does our medical field. The day we stop asking questions and trying to see things differently is the day we stop becoming doctors in my opinion. We are over run with guidelines and practice recommendations that change on a regular basis (in my world this means nutrition guidelines, statin guidelines, coronary stent guidelines, etc). We can memorize the guidelines all we want. Does that mean we “got this?” Hell no. Assuming we know it all and assuming the guidelines are always right is the easy way out. The more challenging and more helpful approach is to know that we don’t know it all, to know guidelines are flawed and don’t apply to everyone, and to know that we should never stop asking questions and never stop learning. Thanks for that reminder!

  3. I far prefer humble doctors, especially as the ones that have assured me that ‘there is nothing wrong’ have all turned out to be wrong. In particular the gynaecologist who was supremely confident there was nothing causing the pain I was getting, but who never the less performed a laprascopy (if he was so sure it was all in my head why was he putting me through a general anaesthetic etc which does carry risk?), then found my fallopian tubes resembled a couple of strings of sausages more than tubes. He was most disconcerted when I was happy because I had proof there was indeed a physical cause for the pain, showing a complete lack of understanding or empathy for my situation. Doctors who admit they don’t know, who are confident enough to say ‘I’ll need to look into that’ are far more likely to get my trust, I’ve also found they are doctors that really listen to what I am saying and who don’t latch on to one thing because it will fit a diagnosis they have in mind while ignoring anything that would exclude it. I’m very happy to say that my current doctors, both primary and specialist are all the latter type.

  4. I have to say that I have a very complicated situation regarding my psychiatric diagnostic.

    My current academic psychiatrist is part of a group at a teaching hospital who specialize in the complex diagnostic group and he follow me since 2010 (7 years and counting) at the rate of a 15~30 minutes consult every 2 months. He doesn’t believe I’m autistic, he does believe I do have a serious disability but in the 7 years he followed me, he doesn’t have any diagnostic for me yet.

    In my case, I absolutely _don’t_ care about the diagnostic label but it is somewhat important for taxation purpose (I’m at the point in life where I can submit diagnostic paperworks to taxation related governmental agencies and get huge payback upon recalculation of my last 10 years of taxes where I paid a significantly big amount of taxes) and a few other things. I have no problem with uncertainty.

    Given the ordeal, I have to get the Canadian equivalent of FOIA request to several governmental agencies who has been part of my career buildup (work still in progress) and other para-governmental agencies; review the result and write down a review for my psychiatrist for the next appointment.

    I also have to write a review regarding my financial decisions after having downloaded 6 years worth of financial transactions from my bank’s website, to be submitted with my next appointment.

    About medical evidence, my psychiatrist even have my genetic workup and a royal bunch of other medical information in the form of tests and result of clinical trial (my own initiative, not asked by my psychiatrist but I do take part in research, either as an assistant or as a subject).

    Alain

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