Insights (Essays)

Insights (Essays) May 2010

The Power of "I don't know"

Neil Seeman

Saying "I don't know" can be a deeply liberating experience. People in healthcare - and in virtually all service industries - do not say this nearly enough. The client ends up suffering.

I learned the power of this phrase in law school; I hadn't read the course notes, and, upon being fingered by the lecturer for an answer, I couldn't fake it. Saying "I don't know," then pledging to the teacher to learn the answer, made me feel at once authentic and committed.

Trouble is, "I don't know" is an alien phrase for many information elites - including everyone from lawyers to accountants to insurance salespeople to what Deepak Chopra calls "Medical Deities" (aka MDs). My colleague Carlos Rizo has suggested an entire course be taught in medical school on how and why and when to say "I don't know."

In a talk called "Empowering Patients" at a spectacular conference - "One Patient, One Record," organized by Kevin Leonard and colleagues of the University of Toronto and patientdestiny.com - speaker Doug Gosling twigged me to the power of "I don't know." When chronically ill patients have access to their full medical record, Mr. Gosling explained, it is very hard to hoodwink them. If a clinician fails to say "I don't know," a patient detects evasiveness.

Perhaps "lie" is the right word. Lawyers will make a fancy case that in rare instances "saving" a patient from the truth is worth the lie. Maybe so. But here's our reality: In 0.2 seconds - the time it takes to blink - it is possible for anyone anywhere with access to the Web to type in a health term into Google and for Google to send back a solid answer.

When you're chronically ill, you are Googling about your illness several times a day. There are many who say we still need "information curators" to sift through the "noise". Not always. I believe Google is making most of us a whole lot smarter about our healthcare. I think most people with chronic illness can learn enough accurate information online in 24-48 hours about any disease to be able detect whether their care provider is faking an answer.

An example: It is difficult at first to distinguish between obsessive compulsive disorder (OCD) and ritualistic behavior in young children. Many young girls (and boys) like to line up their dolls and pillows in a pre-ordained way every evening before bedtime. Insisting that food be organized in a circumscribed pattern on their dinner plate is also normal for a child. OCD is very different, and research published last year in the Journal of Psychopathology and Behavioral Assessment suggests the condition can develop in children as young as four.

When I asked a pediatrician to explain the difference to me one day, his eyebrows rolled sideways, he touched his left upper brow with his forefinger, and gave me a song and dance about how absurd it was to imagine that a four-year old could exhibit signs of OCD. I lost trust in him because he failed a basic humility test: to say "I don't know but I'll try to find out."

Memo to doctors (and lawyers) everywhere: we pretty much always know when you don't know (especially when it comes to our children or aging parents). This was probably true before 1995, when there were a few thousand websites, but far more so today when there are billions. And yet, in a paradox, many professionals today - perhaps to legitimize their existence in an age of ubiquitous information - feel they have to know *everything*. To say "I don't know" is an unthinkable utterance, as if to break honour with a fraternal pledge of feigned knowledge.

True knowledge begins with "I don't know - but I'll try to find out." Ask a patient.

About the Author(s)

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

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