The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge. I supervise residents—they make the decisions, but it’s my name and my ass on the line, so I keep a close eye on things. Some teaching physicians dictate every decision on patients, some do nothing at all. I try to keep toward the end of the spectrum that allows for resident autonomy. When I’m presented with a case, and asked what I would do, I cry foul:
“You are the doctor,” I say. “Tell me what you’re planning. I’ll tell you if I disagree, and I’ll let you know if I disagree enough to override your decision.”
This technique must, like all others, be tailored to the individual learner, but I want them to worry—I want them to think, “if I don’t do this right, no one else will, and a patient will be hurt,” because that is what the rest of their careers will be—being awakened in the middle of the night out of a sound sleep, having to make a quick assessment, and being reasonably sure that you’re right.
Except I’ve got their backs.
Of course, that confidence can lead to arrogance. It’s an occupational hazard. If it’s simply a personality quirk then it’s annoying. If it includes a lack of humility, a lack of knowing what you don’t know, then it is as dangerous as indecisiveness.
It takes years of training to develop the decision-making skills that go into being an effective attending physician.
This is one place where we part ways with the cranks and quacks.
Cranks and quacks lack humility in the face of disease. They have confidence without knowledge. As a real doctor, I know, with complete certainty, that I will have failures. I know that there are some diseases I can’t beat. The variety, complexity, and horror of human diseases have taught me my place. I can’t promise miracles, but I can give statistics.
Quacks and cranks do promise the improbable. They promise to stop you from aging. They promise to stop autism by fighting vaccination. They promise to twist your chi until your malaise relents. Most important, they don’t know what they don’t know, and that makes them dangerous.
The Jenny McCarthys of this world are intellectually lazy. They perceive a problem and develop a potential solution without regard to what may have been done before. They are arrogant and ignorant enough (a bad combination) to think that they have some special insight into a scientific problem that decades, maybe centuries, of dedicated professionals have missed.
Since they don’t understand the science underlying their ideas, they have to invoke an array of deus ex machinae to remove them from their dead ends. Since they know mercury in vaccines cause autism (sic), and all the science disagrees, well then, there must be a vast conspiracy to hide the supporting evidence.
Scientologists know psychiatry is evil and murderous. Since the data don’t seem to bear that out, once again, a conspiracy is invoked that can explain anything (and explanations of “everything” usually explain nothing).
HIV denialists are certain that HIV doesn’t cause AIDS. It must be some combination of malnutrition, drugs, or other infections. This complicated and unproved explanation simply reaches in and plucks the denialists out of harms way as the truth bears down on them.
Lyme disease wackos (the discoverer of Lyme disease had to wear a Kevlar vest for a long time to protect himself from the peace-loving patients) often find themselves with symptoms, but no lab confirmation of their infection. What do they do? Simply change the rules—now, we can define an infection without any microbiological evidence. Deus ex machina. Smoke and mirrors and side-show miracles.
Real science is hard. Real medicine involves giving bad news—really bad news. You share the joys of your patients, but also their pain, suffering, and death. It’s a package deal, unless you make wild promises, conflating false hope with true compassion.
Quacks and cranks aren’t just wrong. They promote suffering. Not just through snake-oil cures and the like, but because the offer a false compassion, one arising from a lie. Real compassion often involves holding a hand and saying, “we’ve run out of tools to fight this. The disease will win. What is left is finding a way to live whatever time you have the best way possible.” Real compassion is painful, but still rewarding.
Confidence without arrogance, humility without indecisiveness, knowing what you do and what you don’t know: these traits, these skills are hard to acquire, hard to teach, hard to master. But the are at the core of medicine. They are the heart of medicine.