Posted by: notdeaddinosaur | March 5, 2013

Not Knowing What You Don’t Know

“The more you learn, the more you realize you don’t know.”

You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.

The implication of this for the practice of medicine is that a little knowledge can be very dangerous.

What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.

I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)

The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it,  it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.

Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing.

I called my handy dandy Hand man, my friend the hand surgeon I have on speed dial, whom I love because he answers my texts. This time, though, I picked up the phone and spoke to him. I explained the situation and my puzzlement. Here’s what he said:

Send him to the ER. He needs to admitted for IV antibiotics for 24 hours. If it’s not getting better by then, he needs a debridement [surgical procedure].

Okay then.

I called my patient and relayed the message. Just to be sure, though, I asked him to call me if they did NOT admit him.

On I went with my day.

Phone rings; it’s my patient calling from the ER:

They’re sending me home.


They’re giving me a dose of IV antibiotics and sending me home on the one you gave me. They gave me the number of a hand surgeon to call tomorrow if it’s not better.


I get on the phone to the ER, and ask to speak to the physician seeing my patient. Turns out it’s a PA, who proceeds to tell me that the hand doesn’t really look all that bad, she’s seen worse, and treated them like this before, sending them out with the blessing of the hand surgeon.

Hm. This is a fast moving infection that has worsened markedly in the last six hours while on oral antibiotics.

Did you consult Hand? I ask.



Long story short, I get the PA to call Hand Surgery (“Though I doubt they’ll come in,”) who successfully convinces the ER to admit the patient on 23 hour observation status with IV antibiotics. By morning (and 4 doses of IV antibiotics), the red streaks are resolving, the swelling and pain are decreasing, and the patient is good to go, to complete the course of orals.

I was concerned enough about this encounter to call the ER and speak to someone *in charge*. As part of our go-round, I was informed that there was always an ER physician available while the PA was seeing patients if there had been any concern, to whom the PA could turn. It was surprisingly difficult to convey the idea that the problem was that the PA did NOT have a concern. She did not believe that she needed to consult either with her supervising physician, or a specialist.

If I had not explained the (expected) plan to my patient, or specifically asked him to call if the plan was not carried out, or if I had meekly acquiesced to the “provider” on site since she was looking at the patient and I wasn’t (though the patient did take and send me a picture, which I was able to compare to one I took of the same injury 6 hours earlier), frankly I shudder to contemplate the outcome.

Primary care isn’t just about knowing stuff, and knowing what you know; more than that, it’s knowing enough to know what you don’t know.

Mid-level providers do not know enough to know what they don’t know. This makes them dangerous. Admittedly these situations are few and far between, which is what allows complacency to flourish. But make no mistake. Their education emphasizes what they know, leaving them with enormous blind spots of hubris into which more and more patients will fall, with predictably disastrous results.



  1. Hi,

    There are mid levels, and then there are mid levels. Just like there are doctors and then there are doctors. I agree that overall doctors know more because of their training, and hence there is less that they don’t know. A truly experienced mid level is a precious thing as they usually have seen more and done more than an average resident. Surely one of the lessons learned in avoiding medical mishaps is the use of the team in avoiding human factor errors. The most junior and less trained person needs to be free to question the most senior. Pilots learned that 20 years ago in cockpits.

    At the end of the day your persistance saved the potential loss of function to your patient’s hand.

    To my mind the problem was more that the PA wasn’t trained to react to questioning by colleagues correctly. That is a system issue in Emergency Departments.

  2. This post is reminiscent of those I used to read by NHSBlogdoctor (remember him?) who was stymied right and left by midlevels whenever he made referrals. The problem seems to arise when care is being managed by an MD who refers and then the patient is seen by a non-MD who then usurps the judgement of the MD who first saw the patient. This is just plain wrong. If a mid level chooses to disagree with the judgement of an MD, then another MD must become involved.

    Good for you to have the patient call you. Another option in this case would have been to call ahead to the ER and speak to an MD there to be sure the patient got the care he deserved. THinking about it, that may be a tactic I will use in the future.

    All the best –


  3. Just discovered your blog (via Bora Z.). Great story. And… this applies to science, research and life in general. Knowing what you don’t know. Important.

  4. […] great medical story makes the point about why it’s important to know what you do know and what you don’t […]

  5. When I was in nursing school I did my maternal/child rotation at a local University hospital. The most experienced nurse was a diploma based LPN, but she’d been in the field for 40 years. Everyone, doctors to patients to janitorial staff, called her ‘Mom’ and she was the one the OBs turned to when they were concerned things might go poorly.

    Same hospital, a year later when I had graduated, a surgical resident I was assisting placed a central line in an artery instead of the vein, then walked out of the room when I brought it to his attention. He was an MD, had *several* more years of school than I had and couldn’t/wouldn’t acknowledge that he had done anything wrong.

    I’m not perfect, never will be, but I’ve seen enough to know that know-it all syndrome flourishes at *all* levels of education, but does tend to diminish with experience.

  6. What I find particularly interesting is when my college non-majors biology students want a second opinion from ME. I am not a doctor, my field of expertise is the mitochondria, and yet they seem to think I know better than their doctor what they should do about a medical concern or problem.

  7. “Mid-level providers do not know enough to know what they don’t know. This makes them dangerous. ”

    Oh wow. So clearly I should make sure I never see a PA or NP, because they’re going to be dangerous, right? I think that’s what you’re saying. Because no matter what their background or experience level, their training combined with their hubris automatically makes the care from one “predictably disastrous”, yes?

    Thanks for the advice! Maybe I should warn all my friends? I’ll just direct them to this entry.

  8. And this is why building a trusting relationship between a primary care doctor and a patient is essential. Imagine what would have happened if the patient had not trusted you more than the he trusted the PA and decided to follow the PA’s instructions instead of yours… *shudder* (I’ve seen an aggressive hand infection take a man from injury to morgue in three days.) Good thing he consulted you before going to the ER.

    Date: Tue, 5 Mar 2013 09:51:49 +0000 To:

  9. I’m not a physician, but I’m a veterinarian, so I know plenty about cat bites. I’d have been one of those horrible patients who threw the PA out and requested a hand surgeon, immediately, if she had argued then tried to send me home with oral antibiotics for something like what you described. You’re absolutely right: that PA doesn’t know how little she knows, and she still doesn’t, because she probably believes your patient would have improved if he’d followed her original plan. Obviously, she has never seen what a nasty cat bite can do to someone’s hand, and until she does, she’ll continue to provide subobtimal care. One of my techs required surgery and a splint for a couple of months. Cat bites are no joke.

    Good for you for looking out for your patient. Scary.

  10. RD, you’re darn right I’ll make sure I never see a PA or an NP.

  11. My comment was thickly veiled sarcasm. I was trying to see if the original poster would try and temper my response with a reasonable disclaimer…something like, “Well, I guess I had a bad experience with this one PA with one patient, I guess we don’t need to condemn an entire profession.”

    But, that didn’t happen. So I’m guessing the OP really WANTS that kind of reaction from the audience…that all who read this immediately assume every single PA and NP is a dangerous, poorly trained time bomb who put all their patients in harm’s way by not realizing that they don’t know everything.

    I’ve had good experiences with PAs, NPs, MDs and DOs. I’ve also had bad experiences with all of the above providers. I won’t make a sweeping assumption about all MDs just because I felt one made a mistake or a lapse in judgement. EM is crazy, and often not-the-greatest decisions are made with incomplete information. We’re all human.

    Let’s take an example here:

    This is just one case. But it’s not the first case where poor MD judgement has resulted in a bad outcome for a patient.

    If I were the OP, I might use this as an example of how all MDs are filled with hubris, don’t listen to nurses, and as a result kill their patients. I might say, “I’d never see an MD – they have so much training that they feel they are invincible and can’t let the patient’s welfare get in the way of their egos.”

    But I wouldn’t, because such generalizations are closed-minded.

    Thank goodness this patient had a good outcome. I won’t make a sweeping generalization of an entire profession based on an isolated case. Even if this isn’t the first time the OP had a bad experience with a PA, I still think such sweeping generalizations are ignorant and closed-minded.

    In a sense, this post is ironic; when you make a statement like:

    “Mid-level providers do not know enough to know what they don’t know. This makes them dangerous”

    …that is essentially saying:

    “I know all there is to know about all mid-levels.”

    …which is exactly what the OP is warning us against. That’s NOT acknowledging that there might be more examples that he / she is not aware of. That’s plainly declaring, “I can’t learn anything more about mid-levels, nor am I willing to learn.”

    I think this attitude makes ANY provider dangerous. If the author of this column truly has this viewpoint, I wouldn’t want he / she providing any medical care for me or my loved ones.

  12. @RD:
    Well excuse me for not responding to your (not veiled in the least) sarcastic response in a timely enough fashion for you. I actually put up another post on the topic (here: that may address your concerns by slightly tempering my original post (written by what’s called the “author” or “blogger”, as opposed to your abbreviated “OP”.)

    Here’s the key point from my follow up post, in case you can’t be bothered to click through and read the whole thing:

    “All I’m saying is that the more you know, the more you know you don’t know. Doctors by and large know more than mid levels (bell-shaped curve understood; some mid levels know more than some doctors, especially when the former are older and the latter are younger) which means that doctors have a better handle on what they don’t know. Which means that in situations more likely to be dangerous, it’s probably a better idea to be dealing with a doctor than a mid level.”

  13. I’m a PA. I’m also not proud. I decided to go to PA school and not medical school. My practice will always evolve under the supervision of a physician. The issue I have with your post is the insinuation that the letters behind an individual’s name determines their level of competence. I know paramedics I would prefer take care of me in certain situations over some physicians I know. The same holds true for NPs, PAs, MDs, and RNs. One case a generalization does not make. For example, my wife is also a PA who works in the Emergency Department. Not long ago she cared for a healthy middle aged male who presented with a painful, incredibly edematous unilateral lower extremity. He had seen his primary care PHYSICIAN (a real doctor of medicine!) TWICE prior to presenting to the ED. This individual had a history of upper extremity venous thromboembolism and a familial history of Factor V Leiden. He had also just gotten off a 16 hour flight from Australia. The first time he saw his physician he was told he just had “extra fluid” in his leg from the flight and was prescribed foot elevation and ibuprofen. The second time he saw his physician he was told he had a muscle strain and was referred to MASSAGE THERAPY! The massage therapist thankfully had the good sense to know better (and she didn’t even have an MD), sensed that something else was going on, did not manipulate his leg, and referred him to the ED. My wife, who comes home from work every day feeling like she knows less than she did the day before and is continually humbled by the experience of caring for patients, appropriately diagnosed him (his entire deep venous system was thrombosed from the common femoral vein on down) and treated him appropriately. This is incompetence on the part of what you would describe as a “fully trained, extensively experienced primary care physician”.

    I know some of my colleagues are very sensitive to criticism about what we should be allowed to do or not to do, the arrangement of our legal and professional relationship with physicians, and the role we play, or will come to play, in the delivery of healthcare in America. I have no qualms about the decisions I made to pursue a professional degree and I usually don’t respond to these types of ignorant generalizations, but the hypocrisy that seeps from your post pushed me over the edge. You presume to be an experienced, competent physician. I would argue that one of the most important lessons to learn in medicine is to never dismiss anyone: you never know who will teach you something. It might be the patient, his family, his nurse, a PA or NP, or the janitor… You’re no better than anyone else just because of what you know (or think you know) and the letters behind your name do not automatically make you a good, or safe, or competent healthcare provider.

    You talk about the “enormous blind spots of hubris” that mid-level providers practice with. I work with surgical residents every day. You want to talk about hubris and ignorance? After the fear wears off (usually by week one or two), there’s nothing more terrifying than a new surgeon who has absolutely no inkling of what he or she does not yet know. And they’re physicians (who, by the way, I sat next to in almost all the same basic science and medicine courses during my PA education). There are some really good people in healthcare (many of which are not physicians) and there are dangerous people in healthcare. Incompetence does not discriminate based on the degree one earned in school.

  14. […] Follow Up: The Physician Assistants and Nurse Practitioners at Walgreens are a poor substitute for a Doctor. Some are so dangerous, they don’t even know what they don’t know. […]

  15. Great point and this certainly applies in other fields. The value of knowing your limits and calling in a second opinion can never be overstated. I am not in the medical field; I am a civil engineer who must work with other people with more limited education and work experience to deliver a product that will affect multiple lives (e.g., vapor intrusion mitigation systems, drinking water treatment systems for temporary military installations). Although their understanding may be more limited than mine, I think it’s a great overstatement to imply they are too proud (or unaware) to know their limits or value a second opinion. I found the delivery of your message to be slightly offensive to mid-level providers or for that matter anyone working under the guidance of a more tenured professional.

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  18. Excellent post. I am facing some of these issues as well..

  19. […] to know about it. That’s the main difference between PA and NP training (and what leads to the not-knowing-what-you-don’t-know […]

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