Lessons in Medicine from the Car Dealership

Midway through my residency, my husband and I purchased a new car. The old one, a well-traveled and well-loved 1999 Toyota, had become a bit of a money pit, so rather than trying to sell it or trade it in at the dealership, we decided to donate it. As we sat with the salesperson reviewing the paperwork for our new vehicle, he explained that we had the option of donating through the dealership; they worked with a particular charity that would pick up the old car if we brought it – and the necessary documents – when we came to pick up the new one. We ultimately decided to go with a different charity, so a few days later, when we returned to the showroom (with our oldest son, who was at that time only six weeks old), eager to drive home in our new car and the salesman asked for the registration from the old one, I stared at him blankly.

“You wanted to transfer the plates from the old vehicle, didn’t you?” he asked, looking and sounding just slightly panicky.

I nodded.

“Then I need the registration from the old car.”

“Oh no! We don’t have it with us. OK, then, we’ll just take the new plates.”

“New plates?” Now he began to look panicky. Apparently deciding on new plates on the day of pickup just wasn’t an option.

“Why didn’t you bring the registration?” my husband whispered as I grabbed my bag and prepared to speed back home to get it. “he told us the other day that we would need it!”

“Because I thought that was only if we were donating it!” I hissed back. I wanted to ask why he hadn’t checked that I was bringing the right paperwork, but I knew why: because in our house, I am the Keeper of the Forms, the Curator of the To-do Lists.  If he had asked, I would have snapped that of course I had everything.

“That’s the title that you were thinking of. We needed the registration no matter what.”

“Well, I don’t know the difference!”

“OK, then why didn’t you ask me?”

“Because I didn’t know I didn’t know!”

It was humiliating and time-consuming: in the end, I drove home to get the registration, got stuck in rush hour traffic, and kept us at the dealership until long after our poor, patient salesman should have been home having dinner and our son should have been swaddled snugly in his crib. The embarrassment stuck with me for quite a while, but what has lasted even longer was the realization that the same type of mistake – not knowing that I don’t know something – can occur in any aspect of my life, and most alarmingly, in my practice of medicine. And there, especially, the consequences can far outstrip the loss of a few hours and getting home late for dinner.

I distinctly remember my drive to the hospital for the first shift of my residency five years ago. It was a night shift – why did it have to be a night shift? – and my brain bounced frantically back and forth among a random assortment of topics of which I lacked, I felt, sufficient knowledge, but which knowledge I felt sure I would imminently be called upon to use in a critical situation. As a medical student, it often seemed that medical knowledge was a single entity, a conglomeration of every detail of a given subspecialty that could gradually be acquired bit by bit if only one worked hard enough. And that once one had acquired this knowledge, one’s practice would subsequently proceed quite smoothly. The calendar that hung in the resident room at the institution where I trained, which listed the schedule of lectures for each week, echoed this sentiment in a tone rather tongue-in-cheek. At the bottom someone had written in all caps: “All the time. Know everything. Stat.”

Along the way, I learned, as most trainees do, that this perception that one must know everything (whatever that means) in order to practice medicine safely and effectively is of course untrue. That life, as so many of my teachers and mentors have repeated, is open-book; specialists may be consulted, colleagues “curbsided,” other opinions or ideas or reassurances sought. Drug interactions and dosages may be double-checked. Symptoms Googled. But the ability to draw effectively upon this multitude of resources still depends on one’s recognition of just which things one does not know. Other than by maintaining a healthy dose of fear and humility, I’m still not entirely sure just how that can be done.

Here we are in July again – the time of year that brings an influx of brand-new, just-barely doctors, into the field. An annual fuss is made about the potential for mistakes and oversights by these newly-hatched first-year residents. But what people tend to forget is that, as of July 1 each year, the individuals who occupy any given position in the hierarchy of physicians who are in or just out of training are, by definition, less experienced than the people who occupied those same positions just weeks before. And I’m in the newbie role again. A few weeks ago I began my fellowship in Pediatric Hematology/Oncology. Tonight I am taking call for the first time.

“I’ll talk to you later!” I said to the attending physician who is on service as I left for the day. “I’m going to call you with every call that I get!” Because here I am, just beginning to sip from an enormous fount of new knowledge, of facts and red flags and management details that I have yet to learn and many of which, most frighteningly, I don’t yet know that I don’t know.

She smiled. She told me that she expected to – wanted to – hear from me regarding every call and question that I received. And do you know what else she said?

“Nine times out of ten, you probably know what to do. But if I get to teach you something along the way, well, then that’s even better.”

Humility? Check. A healthy dose of fear? Double-check. Add to that some pure, old-fashioned academic curiosity – an ingredient that likely helped propel many of us along to whichever stage of training or practice we find ourselves in this July – and I think we’ve got a recipe for at least starting to learn those things that we don’t know we don’t know.


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