Monday, June 16, 2014

Guest post: Two points for knowing what you don't know

I’m driving the kids home from school, winding along Dollarton with afternoon sun glinting off Burrard Inlet, and Saskia’s telling me about the Gauss Mathematics Contest she wrote that morning.

“I left one question blank,” she begins. It’s a confession: a perfect score is off the table. She doesn’t add up test scores, she works back from 100. She goes on, “But I did that because of how the scoring system worked. You got six points for a right answer, two points if you left it blank, and zero points for a wrong answer. I wasn’t sure about the last question, so I just left it.”

I make her repeat that, making sure I have it right, because I know I’ll be chewing on this for days.

They were rewarded for leaving alone what they didn’t know.
Making a wild stab at an answer was worth less than no response at all.
For once, it wasn’t about doing one’s best, but about acknowledging one’s limitations.

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* * * * * * *

I was assigned to a family practice when I began residency in 2000, for several 4-week blocks over the two year program, and callback every Thursday afternoon. It was an established practice on Broadway and Granville, and a good group of doctors, but I dreaded seeing the patients, mostly well-heeled reproductive aged women.

Making a diagnosis and treatment plan on my surgery rotation, or in the emergency room, wasn't a problem, but these women kept presenting with issues that weren’t in any textbook. One couldn’t interpret her baby’s cries; another needed advice on dealing with strangers’ remarks on her child’s birthmark; the next had discovered her teenage son’s porn collection. Working at this family practice was by far my least favourite rotation, and I was doing a family medicine residency. That worried me.

My preceptor and her partners took the entire clinic out for Christmas lunch that first year, between morning and afternoon clinics packed with patients wanting to be seen before the holidays. I remember Sarah pausing during the meal and saying to me congenially, “You know when we knew you were okay?”

I had no idea, but I was relieved they’d arrived at that conclusion.

“Remember that rash?” she asked. “The four-year-old with the vesicles on his legs who’d just come back from camping?”

I remembered. Yet another patient that had had me stumped.

“When I asked what you thought it was, you said ‘I don’t know,’” she went on. “That’s when we knew we had a good resident.”

The other physicians agreed. “We don’t care what you know,” said Joan. “We care that you know what you know.”

* * * * * * *

I teach residents myself, now, and it’s true - I don’t pay particular attention to how comprehensive their knowledge bank is, but to whether they recognize what’s missing. Nothing raises a red flag like a learner who already has all the answers.

And then there are the patient encounters where you can’t turn to UptoDate for backup. Sometimes there really isn’t an answer, in that brisk bullet point way that physicians love. Sometimes the P of SOAP feels terribly inadequate; writing ‘counseled’ or ‘conservative’ or ‘follow’ feels like a fail. Physicians get the God-complex jokes all the time, but from where I sit, we're keenly aware of our limitations. Medicine teaches you how very much is unknown.

That's using the Gauss scoring lens to look at one field in one profession. Imagine if we approached everything from a place of humility.

I read comments on news articles on refugee matters, vociferous ones, that are ignorant of the basic facts of the system. I’ve heard someone predict the eternal destiny of another person’s soul with the same degree of certainty that they state their summer vacation plans. I’ve seen someone with no more than Biology 11 comment with the authority of an immunologist on vaccines.

I can't say that those lessons I've learned in medicine have overflowed into every other part of my life, either.

So how about each of us, the next time we’re in a conversation - with a client, in a staff meeting, on social media or out to dinner - consider whether we truly know the answer to the question at hand.

And if not, take two points for keeping our mouths shut.

Cross-posted at and


  1. your posts are always thought provoking. It makes me feel relieved to see someone so thoughtful and introspective in primary care. Maybe I need to move to Canada to practice. Thank you for another excellent post.

  2. I was reading this on my phone and knew the author long before I had scrolled all the way to the bottom. I love your voice. Great post.

    My two best friends at Montessori School here in Arkansas when I was at the age corresponding to traditional elementary school in the US (roughly 7-11) were Tina and Saskia. I had forgotten that was your daughter's name. I facebook friended my Saskia about a year ago - art curator at museum at a big city in another state wow! I used to love to say her name when I was little, and I was always so jealous of how it sounded out loud compared to my Elizabeth. Never thought I'd hear of another Saskia.

    1. I hadn't heard of the name Saskia until I visited the Netherlands when I was in med school. Randomly met a woman with the name and loved it. It's not unusual there. It was the name of Rembrandt's muse. [At 39 weeks pregnant I saw the Rembrandt exhibit at the Vancouver Art Gallery and saw the sketches of this remarkably unattractive woman. Unsettling.] However - unmistakable uptick in the name in the Vancouver area right now. Hopefully short-lived.

  3. I'm unreasonably proud of myself for being able to answer all the math questions. :-)

  4. I find it funny that the concept of getting docked more for wrong answers then for no answers is new to you. :-). That's how a lot of testing works in the US, including the college board.

    1. I've racked up about 200 college credit hours, nursing school and my BS in the US and I can't recall a single test that gave you points for leaving it blank. I think it's a wonderful way to teach.


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