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We don’t know it all. Why can’t we just say that?

Imposter syndrome, authenticity, and admitting what we don't know

What prompted this post and the mindset I was in while writing it –

  • Tell stories
  • Be yourself
  • Use your strengths to help others

Background (titles and knowledge overload)

Sometimes, let’s just say often, I get overwhelmed when I think about all there is to know in medicine. I realize this is true for most topics, but the majority of my professional “pain points” revolve around medical knowledge and the dynamics between the various professional roles in healthcare.

For me, I see healthcare through the lens of a nurse practitioner. And, for those of you who don’t know, that also includes the years spent working as a registered nurse while completing nurse practitioner training.

Nursing can be a tangled web of confusing roles, titles, knowledge sets, skills, and language. The profession of nursing is misunderstood because regardless of specific training, level of education, or experience – anyone with ‘nurse’ in their title is placed under one big umbrella of function – and called a “nurse”.

However, nurse practitioners have more privileges, gained after additional education and training, typically obtained through a master’s program. Through this training and certification, they add on functions such as ordering diagnostic tests, additional invasive procedures, making diagnoses, billing for their services, and greater autonomy and responsibility. And, just like any other medical professional, much of their skills and function will depend on where they decide to practice. So, even though two people might complete the same program, their set of skills will vary greatly. This is much like any lawyer, doctor, business graduate, etc.

Who am I even talking to?

The reason this is important is because when I began teaching, I had a hard time knowing just what to talk about during certain sessions. The department in which I work (simulation) creates numerous scenarios and clinical skills events for a variety of healthcare students and professionals. So, within the same day and week, you could be creating experiences for nurses, medical students, nurse practitioner students, physician assistant students, flight nurses, school nurses, respiratory therapist students, physicians requesting specialized skills trainings, disaster simulations, patient actors who need to train for their cases, and etc.

All of this is to say, there is a broad range of educations, backgrounds, professional experiences, knowledge-bases, personalities, years since attending school, and so on.

Simply put, it’s tricky to figure out which portion of a very broad field of knowledge should be taught and to whom.

Sure, I’ll do a dissection

Last year, for several weeks of a nurse practitioner event, I taught an “eye lab” for nurse practitioner students who were getting ready to graduate in the weeks following. I did a basic review of anatomy and function, followed by using cow eyes to perform adapted examinations for corneal abrasions & irrigations, leading to dissection of a cow eye to examine the structures, and ending with a quick practice on a simulated eye trainer.

It went very well and I received positive comments about my style of explaining the eye and the fun experience of dissecting a cow eye.

All in all, I considered it a success.

But, there’s a lot more to this story…..

What we don’t talk about

When I was asked about teaching this class, I was absolutely terrified. Even though I had been a nurse practitioner for many years, I could say with certainty that my in-depth knowledge about the eye was very limited. To be honest, it intimidated the hell out of me.

I knew, in my own experience, that I was rarely required to do more than check visual acuity (aka “look at this eye chart and tell me how far down you can read”), examine for foreign bodies or abrasions, and/or diagnose simple eye infections.

But, being able to understand all of the internal structures, how vision works, what makes the eyes move, how to examine them using an opthalmoscope, what a normal retina looked like and what abnormalities might be there – that is an entirely different story all together.

So, after a lot of panic, I did the only thing I knew how to do. I pulled up basic images of the eye, drew a line from each structure, and searched various resources to figure out just what each part did. Then, as I began to understand each part, I started putting them together in terms of how they were connected. I literally made a line from the very front of the eye (the cornea) and articulated, in the simplest language I could understand, the very basic steps of what happens when light enters the eye.

Amazingly, it began to make sense. Again, let me reiterate, I was trying to stay very basic and trying very hard not to get lost in the rabbit hole of every cellular process taking place, every detail of each layer, or every problem that could be found within the eye.

Just what do they need to know?

At the time, I was really just taking a chance. I was taking a chance by assuming that the students I was getting ready to encounter might possibly be in need of a simpler approach to understand eye anatomy. One that didn’t involve reading an entire textbook. I was also betting on my own prior experience in the ER – for which I knew I was never asked to perform surgery or deal with any of the specialized processes within the eye.

Luckily, my assumptions turned out to be pretty spot on. Over the several weeks I taught this event, I informally polled and researched the students. My suspicions were confirmed, once again legitimizing my own personal experience. The majority of NP’s don’t necessarily need to know every specialized detail about eyes because in REALITY, they don’t use this information.

For these students, who were very close to finishing up their didactic and clinical practice training, many had never been asked to perform these skills because the standard seemed to be to “refer” to an eye doctor. I can honestly say that out of all the students over these several weeks, only a handful had ever seen their preceptor perform any sort of internal eye exam nor had they been shown how to do so.

The beginning of instructional design

Now that I have been studying instructional design, I can see that what I had done intuitively for this eye lab was pretty much the initial step in designing any learning experience. It’s an intentional process and a hard look at what exactly we want the learner to be able to do with this information. I think this was best worded recently when someone said “the learning should mirror the real-world task”. Unfortunately, we don’t always remember this.

Thinking about teaching in this particular way, I’ve started to see why it can be hard to accomplish just the right training and why many times, our trainings don’t match the real world task. The reason: we don’t like to admit the “real world task” because it includes not knowing it all. We bombard people with large amounts of information that they instinctively know they will never use.

For one, there is often an untold truth about what we really do versus what we think sounds better. For example, it’s very grandiose and impressive to say that we should know everything about the eye, that we are graduate students and should be past basic anatomy, and that we should be well rounded and well versed in everything in medicine. But, that is just not the truth. And, even worse, believing this and spreading this creates a culture in which we don’t admit what we don’t know. Therefore, we don’t ask for help, we make diagnoses based on limited knowledge or based on “how it’s always been done”, and we make mistakes that have the potential to be fatal.

Is it just me?

I have often felt alone in my frustrations about medicine and it’s unrealistic expectations and bravado. I have suffered greatly from imposter syndrome. And, because it’s taboo to talk about what we don’t really know, it further increases the anxiety around uncertainties and questions about why we do things.

But, what I’m finding is that I am not the only one. I just am often the only one brave enough to admit it. And, that’s a shame. I realized this after killing myself to study a topic so that I could feel “smart enough” to talk about it. When I pushed or challenged students – or other healthcare professionals – they didn’t know nearly as much as they had portrayed on the surface. This is not an insult. This has simply been an eye-opening experience into the culture we’ve created in medicine, in adult life, and in our society. A culture where it’s shameful to admit that we can’t possibly know everything, even in our chosen fields.

Authenticity

Everyone has things they are good at and things they are bad at. My education, experience, comprehension, strengths, and weakness are entirely unique. But, the experience of “not knowing it all” is not.

As uncomfortable as it feels and even though not everyone will agree, I think the only way to actually get better at something is to admit what we don’t know.

Interestingly, the thing about it is, even when someone doesn’t admit that they don’t know about something, it is usually obvious to others who may be too polite to say so. The best way I’ve heard someone say this is “you can’t bullshit a winner”. And, I remember that. We might be able to pretend for a while, but ultimately, what we don’t know will show. And, in medicine, what we don’t know can have tragic consequences.

Overall message. Just be real.

In closing

At the beginning of this article, I shared the thoughts that were on my mind when I wrote this post/article. I am telling my story. I hope to be more of myself, every day – even when it’s hard (because it is). I hope that everyone finds a way to take their strength and help someone else. And, I hope to not only continue to admit what I don’t know but also admit what I don’t want to know.

For my fellow book nerds

Matthew Syed wrote a book called “Black Box Thinking” that digs deeply into the psyche of medicine and the consequences of not admitting weaknesses or mistakes. He compares this to aviation and how they bring mistakes to the surface so that everyone can learn from them. Fantastic read.

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You can also follow me on twitter @brandylrhodes1 and instagram @brandylrhodes

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