BMJ: Those three little words

I still remember the first time I said those three little words. Growing up in a loving Welsh family, I’d heard them said many times. But the first time they roll off your tongue will always be different. You try to choose your moment, but sometimes the words take you, and the listener, by surprise.

If “I love you” are the three most important words in life, then “I don’t know” are the three most important in medicine. They’re also the most underused. Their power comes from admitting that doctors don’t, and can’t, know everything.

For me, the first time I admitted to a patient’s family that I didn’t know the answer was after caring for a young man who died from sepsis. I was a doctor on the intensive care unit, surrounded by fancy blood tests and scans. Yet I couldn’t answer his family’s most basic, most important question. Trying to comprehend what had just happened, his mum asked, “Why him? Why has he died?”

All medical encounters revolve around things we don’t know. Patients and families often challenge us to predict the future, asking, “Will she survive?” or, “When can I go home?” Like the best meteorologists we must integrate science, history, and our gut instinct to make a stab at an elusive possibility that we hope clings to a truth.

Consider a weather forecast of a 90% chance of rain. If the sky stays blue the prediction wasn’t wrong—truth just happened to be found in that smaller 10%. Openness about uncertainty can lead to more understanding: a 90% chance of rain may tell you to take an umbrella, but “I don’t know” is the start of longer, more nuanced conversations.

Looking a patient or relative in the eye while saying “I don’t know” is hard. They’re difficult words to say. It’s hard to admit the limits of our knowledge, and sometimes it means hinting at the boundaries of medical understanding. Patients and families often expect doctors to have solid answers, or they assume that modern medicine can cure them. It can come as a surprise when we don’t and can’t.

They’re also risky words. When you’re standing on the solid ice of reason it can easily get slippery when that ice begins to melt. You can fall, become unsteady, and have little to grip on to. It’s a disorientating and unnerving experience for doctors to say, “I don’t know,” and once you admit the limits of your knowledge it can make you question more and more.

Yet these words also carry immense power: the power of hope, because there may be that chance to recover. They also carry the power to inspire people to strive for a better understanding of what’s not yet known. Even when these things don’t follow and hope is lost, perhaps honesty with yourself and those you care for is good in itself—although I’m not sure about that either. I don’t know.

Matt Morgan and Peter Brindley: Meetings⁠—where minutes are kept and hours lost

It is estimated that meetings add less than 5% to productivity, are mostly about status management, and contribute to 70% of workers feeling disengaged. [1] Oh well, no time for such thoughts: it’s off to the monthly medical meeting. You’re not working clinically, but are dragged back to the hospital. At least you can sport your latest hipster t-shirt rather than those crumpled scrubs. Others dress in Lycra bike shorts that leave nothing to the imagination. Regardless, it’s time to ingest stale coffee, squint at a blurry screen, and balance on a wipeable chair: Let the predictable pantomime begin! But will everyone remember their lines?

Act one

Scene one: The mandatory IT delay

The organiser fumbles with a broken remote control, and cycles through countless menus: “VGA1,” “VGA2,” “AUX,” “Laptop,” “HDMI”. The screen stays as black as the coffee. Attendees mutter awkwardly as wires are un-plugged, blown on, and returned to the same hole. The organiser becomes increasingly red-faced; enter the IT saviour. You worked in Dixons at age 16 and know the dark arts of video projection. You move in, pop a battery in the remote control, and, voila, the screen is resuscitated to a bright white light. You believe you are a hero. Others silently disagree; after all this meeting was close to being cancelled. Ten minutes in, nothing yet achieved.

Scene two: For those calling in from home

An iPhone is balanced on the table and its volume turned to max. Battery power might be at 5%, but let’s give it a go. Multiple passwords are tried, before a picture of a dog eventually appears. At this point the script is as familiar and it is farcical:

“We see you but can’t hear you” 

“Try logging out and logging back in”

“Is the Wifi better in the kitchen?”

Finally, the video becomes clear, and the sound becomes ear-shatteringly loud. An important point is made right as the video connection dies. Twenty minutes in; surely there is more to life than this. 

Scene three: This will never work

It’s time to hear from “the voice.” Namely, that person who has worked more shifts that you have had hot lunches, has saved lives using nothing but a rusty spoon, and even remembers life before flat whites. With both eyes on retirement, he has little time for new initiatives that are really just recycled old ones. Nowadays, he takes delight in saying things that would get new hires struck off yet he receives admiration and the odd bottle of wine in return. 

Act two

Scene one: Why is he even here?

Our next protagonist cares more about the Wifi code and little about the agenda. His power cord is stretched across the entire floor and he has commandeered the room’s only socket. He noisily taps computer keys, and repeatedly checks his beloved phone. He might be studiously taking notes, but is likely just shopping on Amazon. Forty minutes in: if only we had arranged to be paged out. 

Act three

Scene one: Not so fast

Discussion about the clinical rota has concluded, and that contentious checklist has been okayed. A détente is reached that would impress the UN security council. “Onto the second agenda item” says the organizer at which point several actors burst into song: “uhm, just returning to the last topic, am I right in thinking that . . .?” No, dear colleague, you’re wrong, dead wrong, and you would know that if you had been listening. “Perhaps we’ll move on” states the frazzled organizer, “well I think this needs more discussion” the others reply. Fifty minutes in; thank goodness there are no sharp objects nearby. 

Scene two: Crisis averted 

Near the end of our play a villain enters in a cloud of paper and to a cacophony of pages. He collapses into the last empty seat, and is passed the agenda that he has clearly not pre-read. He tries unsuccessfully to obtain a few drips of coffee, and is just about to bite into the last stale muffin when he remembers another meeting he needs to be at. Everyone breathes a sigh of relief that they will be spared his attempt to highjack the agenda. He leaves and likely won’t be heard from for months. The meeting has now reached its allotted 60 minutes: time to conclude the performance.

Closing scene

 “Right, the next meeting is during half term, shall we meet anyway?”

“YES!” is the unanimous reply.

“Any future agenda items?”

“Can we talk about whether these meetings are truly useful” says a quiet voice in the back.

“Sorry, there’s simply no time”. 

Curtain drops, exit stage left. 

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter: @docpgb
Competing interests: None declared

[1]  Bruce Daisley is the European VP for Twitter. He hosts the podcast Eat Sleep Work Repeat ad has authored the book “The Joy of Work”.

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Hospital doctors should step outside BMJ 2019 (Published 06 August 2019) Cite this as: BMJ 2019;366:l4914

Last year I did something I found difficult, unsettling, and risky. Yet, in many ways, it was a simple act that community health workers do every day. It didn’t involve a complex procedure or a new treatment. I even wore a pair of jeans while I did it.

Last year I stepped into the home of a patient I’d cared for while he was critically ill many years before. I left the safe neon confines of “my” hospital and entered “his” softly lit world of home. I was the visitor, the guest in his life rather than he in mine. That experience changed me. It was a powerful way to navigate the fog of medicine that surrounds us in hospitals.

Until then, my “patient follow-up” had involved seeing an empty bed in the intensive care unit. This meant that the patient had either died or got better. Occasionally I’d expand this window further, by visiting people on the ward after leaving intensive care or by looking at their date of discharge on the hospital computer. To my colleagues, a “did not attend” at an outpatient clinic may represent something similar: the patient didn’t come, presumably having got better or perhaps worse.

This binary view of the future is, of course, not real life. While survival is good, it’s not always good enough, and we should strive towards what’s important to patients. What better way to frame these hopes than to see patients living their own life? Before I saw the other side of that journey I was ill prepared to advise on what route to take. This form of follow-up may be a rare concept in hospital medicine, but it’s one we need to learn about from our community colleagues, who have known this for decades.

As I stood in that person’s home—seeing the adapted shower, hearing the children playing in the garden, smelling the home cooked food—I was reminded of what medicine’s really about. Not a ward discharge, not a hospital discharge, but life returning.

I’ve come to think of this as “deep follow-up,” and I believe that it may help combat nihilism when treating conditions such as traumatic brain injury or cardiac arrest. I later visited a family where life could not return, where the patient had died. But this, too, may give us the humanity to have difficult conversations about survivorship earlier and may help shared decision making about life sustaining treatments.

Of course, this kind of follow-up needs to be done safely, with support for all parties. It may not be suitable for all patients, all families, or all staff. It isn’t practical for every encounter. But perhaps we can occasionally flip the narrative and, instead of patients booking an outpatient appointment with us, book a walk in the park with them.