The importance of saying “I don’t know”

The importance of saying “I don’t know”

Vijay Gopichandran


“I don’t know” are the most difficult three words to speak out for most people. These three words superficially mean the lack of knowledge on a subject. However, these words have a far deeper meaning embedded in them. To some people, “I don’t know” means declaring openly that they are vulnerable. As knowledge is power, the lack of it is vulnerability. By openly accepting that they are vulnerable, they are exposing their weakness to the person standing opposite. “I don’t know”, to some, means that they are incapable of knowing. To them, it means that they are accepting their inability to know something and their lack of competence. To certain others, “I don’t know” just means an open declaration that they do not care to know or that they are lazy and do not want to know. These embedded meanings behind “I don’t know” make them three of the most avoided words. This is very much true among medical doctors.


Medical doctors are trained to believe that they must have answers for all questions related to health and the body. The society also expects medical doctors to know everything related to the body. This armor of invincibility that doctors wear (or are forced to wear by the society) makes them refrain from using the three words more than anyone else would. This morning, I was having a lengthy conversation with my sister. A loved one in her family is suffering from terminal cancer and is constantly groaning in pain. However, his palliative care expert told her that the groaning is not out of pain but some other psychological condition. My sister asked me, “how do doctors make out whether a groan is due to pain or not”. I said, “I don’t know”. She was intrigued that I didn’t know. “Don’t they teach this in your medical school?”, was what she asked. My sister’s question reflects society’s belief that doctors know everything there is to know about the human body.


This story goes back almost 17 years. I was a fresh graduate from medical school and was working as a junior resident with a senior endocrinologist in the city. My routine job was to take the history, perform a physical examination, review lab reports and present the findings to her. She would analyze the patient’s case and we would make treatment plans. I would also occasionally double up as the laboratory technician, phlebotomist, and pharmacist when these people were not there in the clinic. It was a routine clinic day. My senior doctor was in her clinic in another hospital across the city. I was reviewing her patients in this clinic and preparing to present their cases to her when she would come here in another hour or two. As I was going through the history of a patient, my senior doctor called me on the landline phone of the clinic. (Those days I did not have a mobile phone) She said, “I am sending in a young girl to the clinic there. You must do an ACTH stimulation test for her. She will be there in the next 10 mins. Can you do the test?” I replied in the affirmative and cut the phone line.

The truth is that I had not even heard of what the ACTH stimulation test is till then. Now I know what it is. I will first describe what it is and then tell you what happened. There are some clinical conditions which affect the hormonal system of the body in which the production of an important hormone, cortisol is reduced. This leads to a condition called Addison’s disease. Due to low levels of cortisol hormone in the blood, these patients have low blood pressure, weight loss, extreme weakness, and abdominal pain. This condition could either be due to defects in the adrenal gland which produces the cortisol hormone, in which case it is called primary Addison’s disease or it could be because of problems in the pituitary gland, which now fails to stimulate the adrenals to make cortisol hormone, also known as secondary Addison’s disease. One of the ways to differentiate between the two is to do the ACTH stimulation test. ACTH is a hormone secreted by the pituitary gland, which when deficient can cause secondary Addison’s disease. So, when ACTH is injected into the patient, their adrenals are stimulated and they secrete cortisol. Whereas in primary Addison’s disease, since the problem is in the adrenal gland, even injecting ACTH will not lead to the secretion of cortisol. In the ACTH stimulation test, small doses of synthetic ACTH are injected into the patient. Their serum cortisol level is tested by a blood test before and 1 hour after the injection of ACTH. If the level of serum cortisol increases after the injection, it indicates secondary Addison’s disease and if it doesn’t, it indicates primary Addison’s disease.


But 17 years ago, I did now know any of this. The young girl was brought to the clinic exactly 10 mins later. The girl’s mother handed over a small vial of ACTH, a 250 ml bottle of normal saline, a 2 ml syringe, and a butterfly intravenous catheter. She also handed over a note which read – “Perform the ACTH stimulation test. Inject 1 microgram of ACTH through an indwelling butterfly catheter. Draw serum samples before and 1 hour after injections”. The instructions sounded clear. So, I gained confidence. I started the intravenous cannula and drew 2 ml of blood into a yellow top tube. Now was the part when I was supposed to inject the ACTH. The vial of ACTH read that it contained 250 micrograms of ACTH in 1 ml. Now that means I had to give the child 1/250 ml of this solution. How am I going to do that? How am I going to draw 1/250 ml into a 2 ml syringe? Is this a joke? I didn’t know what to do. I can see the smart ones among you laughing at my predicament. I was really that dumb those days. Today I can easily remove 1 ml of normal saline from the 250 ml bottle, inject this 1 ml of ACTH into it. Now every ml of the saline contained 1 microgram of ACTH. All I would have had to do was to inject 1 ml of that diluted solution into that girl’s vein. But I had no clue then. And like all doctors who are freshly minted from medical colleges, I was too arrogant to accept that “I don’t know”. I felt too uncomfortable to ask anyone in the clinic. I dare not call my boss and ask her, lest she thinks low of me. I was in a very fragile state of insecurity that I lost all sense of right and wrong. I just withdrew the full 1 ml of the ACTH into the 2 ml syringe. I pushed out almost all the liquid out of the syringe, leaving just a little bit, and I randomly injected whatever was left into the IV cannula of the girl. An hour later, I sincerely drew the blood sample in another yellow top tube from the same cannula and sent the girl and her mother home.


Almost an hour later my boss came to the clinic and on her way to her chamber, peeped into the room where I was sitting, gave me a broad smile and asked me to come to her room. As soon as I entered, she gave me a bar of five-star chocolate and said to another colleague, also an endocrinologist seated across her table, “He has done a fantastic job today. Even my senior post-graduate fellows would call and ask me for instructions to perform an ACTH stimulation test. But he already knew and did the test without asking for any help” I was holding the 5-star in my hand and was looking at it intensely now. Part of my look was filled with shame, part of it was embarrassment. I didn’t know what to say to her. There was a war raging inside my head – should I tell her that I didn’t know how to do it and so did a botchy job, or should I just let it slide? My better sense prevailed, and I decided to confess, as I did not want any harm to be done to the child because of a wrong diagnosis and a wrong treatment. So I told her that I did not know how to draw 1 microgram of ACTH in the 2 ml syringe and so I gave some approximate dose. My boss completely lost it. Being a highly patient-oriented, sincere, straightforward and ethical clinician, she couldn’t accept the fact that her patient was given an “approximate dose” of a highly potent hormone. She gave me a sound piece of her mind.

She said, “I don’t believe that you could do that to a child. How could you give a wrong dose of such a potent medicine to a child? Would you have done this to your own child? To your sister’s child?” By now I was trembling in shame and disgust over my own ego and insecurity. If only I had asked someone for help, I would have done the right thing. She said, “Do you know the cost of ACTH injection? One vial cost more than Rs. 2000. You have completely thrown that amount down the drain.” This made me feel even more guilty, as the girl and her parents did not seem to be that affordable. I kept repeating that I am extremely sorry. But ‘extremely sorry’ was not going to undo any of the mistakes I had done that day. The most important thing I learned that day was, “I don’t know” is a very important 3 worded statement that I should learn to say out clearly and loudly when I did not know something. Fake pride that stems out of deep-seated insecurity is not helpful for anybody. It is never wrong to accept my own vulnerability and lack of knowledge. In fact, exposing my vulnerability the first time, helps me learn. Learning builds knowledge. Knowledge gives power. And that power removed my vulnerability. There is a need to accept and acknowledge my vulnerability in order to overcome it. I follow this meticulously now. After that incident, I have tried my best to freely and liberally say “I don’t know” when I really didn’t know. I have used these three words in all earnestness so that I would not have to use them again in the same context. This, I think is an important lesson for all doctors and doctors to be. Inability to accept that I don't know is more disabling than not knowing itself.