Thread by @PaulNWilliamz

How to not know stuff – a thread for new attendings by someone who doesn’t know stuff.

Let's pretend there's a funny gif here.

1/18

There is a lot of great advice out there for new interns and new upper years, but I haven’t seen much for new attendings.
Being an attending is great—you get your life back in innumerable important ways, and you get paid more commensurate with the stakes of the job.
2/18

I personally found the transition terrifying. I internalized the fact that once you finish “training,” you are now expected to know all the things that need to be known. If you were found out not knowing something, you could expect public shaming.
This is of course bananas.
3/18

The misconception is that residency trains you to be a good attending. The fact is--residency gets you to the starting line. Being an attending is what trains you to be a good attending. And it takes years (full disclosure-I’m still not convinced I’m a good attending).
4/18

Repeat after me—it is literally impossible to know everything you need to know to take care of patients. There—doesn’t that feel better? No? Okay, read on.

5/18

You will see many, many results that you don’t know what to do with. This is normal and expected. Some will resolve over time, and some require immediate attention. Until your barometer is good enough to know the difference, assume the latter.

6/18

Don’t just sit on abnormal results you don’t know what to do with. Read UpToDate, consult your friends and colleagues, and come up with a plan to forward the care, and execute it promptly. This feels much better than sitting on a result and generating anxiety.

7/18

Talk to your consultants. Shake off the residual dread from residency. You’re no longer calling sleep-deprived fellows in the middle of the night. You’re discussing a shared patient with a colleague, and they will be glad you called. Usually.

8/18

Build a cadre of consultants that you trust and can call with questions. You may know these folks from residency, or sense they share a similar approach to patient care. You know how nice it feels to know the answer to something? Give them that gift.

9/18

Discuss challenging cases with colleagues in your department. Guess what—they like medicine too! And they like helping people! They will be secretly glad that they are not the one with the challenging case this time, but will use you as a sounding board later. Win-win!

10/18

What happens when you have learners with you, and they ask you a question you don’t know the answer to? Sweet mercy, they’ll know you’re a fraud! You could say “I don’t know,” shrug, and move on. Pithy and to-the-point, but not really helpful for patient or learner.

11/18

Or, that old chestnut “Why don’t you look it up and let me know?” Who doesn’t love the classics? At this stage, they might know what you’re up to, but this is probably an acceptable maneuver if something isn’t time sensitive.

12/18

A particular favorite is asking your resident to teach the team when someone asks a question. This way, you can give feedback on the teaching, supplement the points, and you might learn something while you’re at it.

13/18

For especially challenging cases, I will straight up admit I'm struggling and ask my senior residents for advice.
This may feel weird, but if you’ve ever had a mentor or role model ask you for advice, it feels great. You may not use it, but it can be a great morale booster.
14/18

Of course, saying “I don’t know the answer to this, let’s look it up together” is often the ideal.
At the end of the day, teaching the process may be more important than teaching the facts.
How and where you look for answers become the key teaching points for your learners.
15/18

Role-model not knowing. Do it out loud. Role-model reasoning out loud, looking for answers, and asking hard questions. There is nothing embarrassing in any of this—it is literally the job you are getting paid to do.

16/18

If you learn something from a consultant, say out loud, in front of your team: “I didn’t know that. Thank you! That’s great!” Same for when you learn something from a resident or student, which happens all the time. We are supposed to continue to learn. That’s the point.
17/18

In summary, it’s okay to not know stuff, but have a plan to address it.
Talk to your colleagues-they will appreciate it!
Role-model not knowing stuff for your trainees, but also use it as an opportunity to teach how to learn, and to learn together.

18/18