Tall-in-the-Saddle Confidence

While the funny story of Yes Prime Minister has given me hours of pure joy, the dialogue inside this witty comedy is a classic in itself.

"May I just clarify the question? You're asking who would know what it is that I don't know and you don't know but the Foreign Office know that they know, that they are keeping from you so that there is something we don't know and we want to know but we don't know what because we don't know."

Sure, politics and clinical medicine are utterly different apart from the common theme that we know really little in both situations. “He who knows best knows how little he knows," as Thomas Jefferson noted before. The American Journal of Medicine recently devoted a whole issue on the overconfidence of medical doctors who "think a lot of patients are cured who have simply quit in disgust." When I say "quit in disgust", I am referring to those who leave the doctors, as well as those who leave this world and never return to the doctor's clinic.

In the high-tech medical world nowadays, the low-tech hospital autopsy - not the crime-solving forensic autopsy glorified in television, but the routine autopsy done on patients who die in hospitals - is a rarity and seldom performed (to, believe it or not, unravel the diagnostic errors of medical doctors).

The cognitive pitfall of “not knowing what you don't know” is a situation perpetuated by the (all too often biased) feedback that most of we doctors get. True, our patients will return to our clinic and give us an idea how good we are making diagnosis. Is this feedback really what we want, though? The nub of the issue, however, concerns the characteristics of patients who will return to the same doctor. Think about it. Why should you go back to the same doctor who has made a cock-eyed and silly diagnostic mistake? For the similar reason, a guy who died of a mysterious blood clot lodged in his lung can never get back or feedback to his dear doctor.