We had a great faculty when I was a veterinary student at Virginia Tech, and from what I hear this is still the case today. In particular, my clinical instructors were very helpful and memorable in not only the material they taught, but also in the lessons they shared from years of practice. Rattling around in my mind over the years are many stories and pieces of advice that are still quite significant for me after 16 years of practice.
Recently I was reminded of a quote from Dr. Ed Monroe, one of our internal medicine instructors. He also co-wrote the internal medicine textbook we read. Needless to say, Dr. Monroe is a very smart veterinarian and a great instructor. However, despite his knowledge base and competency, he continually told us “Remember, if you think you know everything, then you don’t know anything.” I was impressed by this thought because it’s not what you think you’re going to hear from the guy who literally wrote the textbook. But now I know exactly what he meant.
In any given day in our veterinary hospital, we will see an amazing variety of cases. Sure, there are the puppy and kitten visits, but our time is spent more with cases like kidney failure, orthopedic injuries, neurologic degeneration, behavioral problems, major trauma… the list goes on and on.
With a great knowledge base learned in school, as well as plenty of years in the trenches, you might start to think that you’ve seen it all. Real life shows us that is never the case! I am amazed that nearly every day I see things that I’ve never seen before, uncommon diseases, unusual presentations of common diseases, or just dogs and cats finding new ways of messing themselves up. “Real life medicine” definitely keeps me from getting bored.
For example, I recently saw a dog for a recheck after a dental cleaning with some extractions. He initially came to us when his owners became concerned about some really bad breath and what seemed like jaw pain. Sure enough, he had a few badly infected teeth that were actually loose. I knew we needed to extract them. Dental extractions are something we do nearly every day, so no problem. He came in the following week and the bad teeth came out just fine, although we did note there was more bone loss than normal around the affected tooth roots. He recovered well, but a few weeks later he started having some more odor and mouth pain, and that’s when I saw him again. Opening his mouth, I was quite shocked to see a few new areas of major bone loss and infection around teeth that looked just fine during his procedure and x-rays. After a bit of researching and consulting, I learned that there is an uncommon autoimmune disease where a dog’s immune system can start attacking the bone around the tooth roots, causing rapid dental disease and infection. How have I never seen this before in 16 years of busy practice?
If you think you know everything, then you don’t know anything.
I often come back to this quote because it keeps me humble and makes me a better veterinarian. I think it also applies to just about any profession out there, as well as life in general. When we become overconfident in our knowledge and experience, we stop searching. There are always other possible diagnoses and other possible treatments, and if we think we know everything, we are going to close the door to those possibilities. That makes for bad clinical practice. No, I don’t right away look for the exotic possibilities when faced with a seemingly common problem, but thanks in part to Dr. Monroe, I keep myself humble enough to know that… I don’t really know.
Another problem I see in medicine these days (and this includes human medicine) is that in this newer era of “evidence-based medicine,” we are becoming increasingly dependent on evidence and less dependent on experience and critical thinking. Evidence-based medicine simply describes the common-sense method of integrating clinical experience and patient values with the best medical research when making decisions about patient care. This is not a new idea and I definitely do my best to practice this approach. The amount of medical research performed over the past 20 years is staggering and is a wonderful addition to our understanding of health and medicine.
But what happens when the information from a great study just doesn’t quite fit with our case? What happens when our evidence is disproven just a few years later by another study? And what about the problems we encounter that simply have no relevant study to learn from?
I often think of eggs and coffee. It seems that every five years there is some study that shows eggs are good for you, then eggs are bad for you. Coffee is good for you. No, wait, coffee is bad for you. Statins are good for you. No, wait, maybe they’re not.
If you think you know everything, then you don’t know anything.
Dr. Monroe’s quote also tells me that not only do I have to be humble and keep searching for other possibilities, but also to use my head and think. There is a ton of really important research out there, but it is the clinician’s job to integrate that information into decisions about care. If that is done with overconfidence, we may find we are putting our patient’s health upon a house of cards. If this integration is done with humility, we are more likely to use our critical thinking skills to make sure our decisions make sense and our patient’s health is on a good foundation.
Interestingly, I think it is the wild animals that actually know everything. They know what to eat, how to raise their young, and how to survive in the wild.
