Matt Morgan: Those three little wordsBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5918 (Published 15 October 2019) Cite this as: BMJ 2019;367:l5918
All rapid responses
“I don’t know” are perhaps the most important three words in medicine . I am a physician in an emergency room and believe this very strongly. Our knowledge in clinical practice is overshadowed by what we don’t yet know. For example, we don’t know what illness the next patient will suffer from. We don’t know if it will be a common disease or a rare one, if it will be life-threatening, or how the patient’s condition will evolve. This is the uncertainty we deal with in medicine, which contribute to the uncertainty in the clinical thinking that guides physicians’ actions in clinical practice. That uncertainty is reflected in all aspects of clinical practice. For a long time, people have tried to find certainty in medical theory and practice and so improve diagnostic and therapeutic efficacy, but that uncertainty remains, and new uncertainties are sure to emerge as some certainties are hammered down.
In ancient times, the field of medicine developed through practice with the goal of resisting fatal diseases and alleviating the suffering of patients . The famous Hippocratic Oath, with its “first do no harm” put to words the priority of patient safety more than 2,000 years ago . Even if one cannot cure the disease, the absolute need is to not harm the patient. However, only toward the end of the 20th century did patients’ safety became comprehensively investigated. Research into medical practices at Harvard Medical School reported in 1991 that 3–4% of adverse events were related to hospitalization . The book, To Err Is Human, published in 1999, showed that in that year more people died of medical errors than from traffic accidents in the United States, and the adverse events related to medical interventions were reported to be the third leading cause of death among citizens of the United States . The World Health Organization (WHO) reported on its website in September 2019 that the “occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world,” and up to 80% of these injuries could be prevented 
These findings have sounded an alarm to physicians; when we encounter medical uncertainty and deal with patients’ vibrant lives, we should consciously use critical thinking, say “I don’t know” aloud, and respectfully question and revisit our clinical decisions and therapeutic regimens with the aim of putting patients’ safety first.
Physicians encounter decision-making in clinical practice every day and constantly use clinical thinking to provide patients with diagnostic and treatment decisions. Establishment of a safety-oriented clinical thinking system is the only way to ensure medical safety. Respect of life is the foundation of medicine, and clinical thinking that respects life underlies patient safety. Following this, the first principle of clinical thinking is to first rule out the possibility of life-threatening diseases during diagnosis .
Clinical thinking has not seen much emphasis or recognition in the past. Diagnostics has focused excessively on common diseases . Admittedly, experienced physicians may arrive at correct diagnoses immediately. However, experience does not guarantee this. Regardless of how experienced and skillful a physician becomes, he or she still cannot guarantee that they will always be at their best. Accumulation of experience requires time and is a process, and patients’ lives and pain may not have years to spare.
The principle of clinical thinking should be to first rule out the possibility of life-threatening conditions during diagnosis, which requires that the utilitarian view be abandoned. Utilitarianism often considers life-threatening illnesses rare, thus whoever bases their decisions on the principle of ruling out the possibility of life-threatening diseases during diagnosis may be suspected of overtreatment. However, each life is unique and valuable. Each life is of infinite value to the person who holds it, and this value cannot be measured by utilitarianism .
To practice clinical thinking by first ruling out the possibility of life-threatening diseases during diagnosis is also a basic tenet of medical humanities, the core of which is to first respect life and to protect patients’ safety . To integrate medical humanities into clinical practice, it is first necessary to integrate medical humanities into clinical thinking. We should practice the essential purpose of medicine, which is to prioritize patients’ safety, to dare to admit “I don’t know,” and to let “I don’t know” become the starting point and the motivation for our constant pursuit of respecting life and fostering patient safety. Ultimately, a workflow and safety concept should be established so that it is easy to follow the correct procedures and reduce the likelihood of mistakes.
Competing interests: No conflicts of interest declared.
Author contributions: Jianguo Li had the idea for the article, Qian Zhao performed the literature search, Hui Guo wrote the article, and Jianguo Li is the guarantor.
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Competing interests: No competing interests
This article is entirely sensible - of course doctors can't possibly know everything, any more than any of us can, and there is honesty and humility in saying so.
I have been seriously concerned, however, to discover that even these important three little words 'I don't know' have been exploited in a way that has effectively dismissed very real issues that patients have been experiencing, especially with 'safe and effective' (sic) antidepressants, including dependence and withdrawal issues - assigning these to 'medically unexplained symptoms'. I have been writing about this for some time, initially for GP View (1) and most recently for BJGP (2).
I wish to draw attention to the still widely recommended RCPsych/RCGP 'Guidance for Health Professionals' (2011, updated RCGP 2014) (3). Doctors have been actively encouraged to 'not know' (and indeed to 'not learn') about the effects of these very widely prescribed medications and to:
"Use 'word scripts' to encourage a shared plan; Be open about your uncertainty yet reassuring that a serious cause is unlikely, but stress that you will keep an open mind" (3).
Patients' experience, at the receiving end of such interactions, has been of distress and desperation at not being believed by their doctors, who in turn consider them as 'heartsink'/'difficult' patients. This has had a very detrimental effect on doctor/patient relationships.
The recent announcement by NICE (4), following the publication of the PHE review October 2019, is the first glimmer of (long overdue) recognition and acknowledgement of patients' experiences with antidepressants that have been hitherto mostly assigned to 'medically unexplained symptoms' of 'unknown aetiology'.
(1) Brown M. Update: Managing patients with medically unexplained symptoms. GP View 25 Sept 2017 https://gpview.co.uk/update-managing-patients-with-medically-unexplained...
(2) Brown M. Unexplained physical symptoms: What is being missed? e-letter BJGP 25 April 2019 https://bjgp.org/content/69/681/e246/tab-e-letters#unexplained-physical-...
(3) Chitnis A, Dowrick C, Byng R, Turner P, Shiers D. Guidance for Health Professionals on Medically Unexplained Symptoms – 2011; Royal College of General Practitioners & Royal College of Psychiatrists; 2014. https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/~/media...
(4) Iacobucci G, NICE updates antidepressant guidelines to reflect severity and length of withdrawal symptoms BMJ 2019;367:l6103
Competing interests: No competing interests