Knowledge Part 1:  I Was Seldom Wrong When I Was Single

I was seldom wrong when I was single. 

I don’t remember what it was we disagreed on. It was many years ago while Sarah and I were engaged. I stopped and visited her at her work. I said something and she corrected me, or perhaps she said something, and I corrected her. I don’t really recall which way it was or what the issue was. It was something very minor, but I distinctly remember being frustrated because I was sure I was correct.

I wasn’t. 

I have since learned over our 30 plus years of marriage that I am occasionally wrong about things.  Maybe it is an address or remembering some detail of an event. Usually, it is about something not too earth-shaking, but there are not infrequent times when I am wrong. We even joke about it together.  When we find that one of us was wrong and the other right, we will pretend to swallow hard and act like we have to squeeze the words out, “I was wrong and you were right…” 

Marriage teaches you humility. More generally, being close to any other person helps refine you. It rubs off your rough edges. It also can be a helpful tool to not get things wrong. I know it may not be proper grammar but, “Together I end up being correct a lot more often than I am on my own.”

I was seldom wrong when I was single.  

No. That is not true. I did have things that I got wrong when I was single, I just seldom knew that I was wrong. 

Lesson one was that I can sometimes sincerely think I am right but be wrong. 

When we bought our first house in Michigan, it didn’t have central air conditioning. We had grown accustomed to having air conditioning having lived in Florida and Virginia. We hired a contractor to add a central air conditioning unit to the house shortly after we moved in.  The night before the install I went down to the basement to try to figure everything out. I shined a flashlight into the ceiling and looked for areas where they could pull the tubes and pipes necessary to complete the job. I was anxious about it. It looked like it was going to be a challenge to get around the small and tight spaces based on where the furnace was installed. 

I grew up on a farm. There I learned a do-it-yourself attitude. If something was needed on the farm you just needed to take care of it. It was a great way to grow up. To this day I tend to be independent and confident to tackle “do it yourself jobs” at home. 

We have a classic family story about my dad doing something just from looking at a book. My uncle worked for the state police. Someone had hit a deer with their car but didn’t want the meat. My uncle called and asked my dad if he would like it. My dad went to the scene and picked up the deer and brought it home. My dad had not been much of a hunter. It was now the middle of the night when my dad realized he had never learned how to clean or dress out a deer. He did, however, have a love for books. He went to the bookshelves in our den and pulled out a hunting book. There he read how to clean a deer. He went back outside to work on the deer and did a fine job. 

And so, the morning of our air conditioning installation, as a young homeowner I worried about how “we” were going to get everything done.  But I had to go to work. I was not able to be home to help them install it and figure it all out. When I came home that night, I rushed down to the basement to see how things had gone. It turns out that they had no problem whatsoever. They had efficiently and cleanly installed everything. They were already gone. The air conditioning unit was installed, and our house was nice and cool. That was great! They made it look easy.

It is possible to take on new challenges, to read, and do things for yourself. But I have learned there is real value in hiring a professional. They have, by training and experience, acquired many lessons and techniques that I often would never think of. It is one thing to learn how to do something new. There is a level beyond that, however. There are professionals who know much more than I can learn by just reading and trying to do it by myself.

Lesson two was the value of a professional.

As far back as residency I have had an interest in heart failure. The pathophysiology along with the ability to leverage medicines to help patients get better has been my professional passion. I treated a lot of patients with heart failure during my time as a primary care physician. Later, I had the privilege (thanks to a supportive and understanding wife) of returning to training for cardiology. Advanced heart failure (AHF) itself was not yet a subspecialty but based on my passion for the science and care of patients with heart failure, Sarah supported me in my decision to take on an additional year of training in heart failure at the Cleveland Clinic after my general cardiology fellowship. I went there so that I could become an expert (a true professional). 

Before I went to my AHF fellowship I thought I knew quite a bit already about the care of patients with heart failure.

It was about 3 months into the training when the realization hit. I remember sitting in the small cubicle area for the heart failure fellows with my co-fellows Maz and Ken. We were talking about things that we were learning that were surprising us. What was bothersome to us was not that we were learning, but that we were learning things that we didn’t know that we didn’t know. 

Let me explain:

• There are things that you know.
• There are things that you know you need to learn.
• There are however also things that you don’t know that you don’t know. 
  • These are more dangerous because you don’t even know that you have a gap in your knowledge.

We agreed that we needed to keep a list of the things that “we didn’t know that we didn’t know.” Let me share some examples. Most of these won’t mean a lot to the non-medical among you but they are important concepts in heart failure:

1. Chronic heart failure patients often don’t have the usual signs of heart failure (rales or edema).
2. You have got to learn how to read neck veins.
3. When management is confusing a pulmonary artery catheter can bring clarity.
4. Intravenous vasodilators can improve cardiac output and help you get patients stable.
5. Diuresis can improve cardiac output.
6. Mitral regurgitation is dynamic and there is interplay between cardiac remodeling, degree of decompensation and the severity of mitral regurgitation.
7. Transplant is real, effective, and amazing. Patients can go from looking nearly dead to being very alive. 
8. Sometimes you need to imagine what your patient could be if their heart were to get better.  (Patients who look close to death can come back to life with mechanical circulatory support or transplant.)

Before my advanced heart failure fellowship, I thought I was good at managing patients with heart failure. The truth was that there were things that I didn’t know I didn’t know. My training in Cleveland helped me to get better in ways that I didn’t even know I needed.  It taught me things that I wanted to know, things that I didn’t know I would want to know, and things that I didn’t know that I didn’t know.

Lesson three was about “The things I don’t know I don’t know.”

I remember dreaming up some research ideas in fellowship. I would go to PubMed and pull articles and research them. As I did so I would begin to think myself really very clever and smart. I would dig deeply into the available literature to make myself an expert on a tightly focused topic. I went to one of my attending physicians and proudly presenting my ideas. He was kind as he worked with me, but I soon discovered that on each topic his knowledge was far greater than mine. Before meeting with him, I thought I was really smart. Each time he would surprise me by knowing all that I presented to him and much more. 

When I went to him, I was proud thinking that I had left the kids’ area and was swimming in the deep end of the pool. As I met with him, I would realize that he was swimming in depths of the ocean. It was humbling but important for me to learn. 

On another day I was rounding with a different attending physician. I made some comments and asked a simple question. He smiled and walked me back to the fellow’s cubicle area. He took down a large textbook off the shelf and opened it to an area that answered my question. After he left, I looked at the name of the authors on the binding. He had literally written the book on the subject. 

There are multiple layers of knowledge. Each of us functions based on the knowledge that we have. The more knowledge you gain, the greater depth of understanding you bring to your decision making.

I see the multiple layers of knowledge daily in my medical practice. When I was junior in my career things were simpler. The more experience I gain the more complex each situation becomes to me. The wheels turn rapidly in my brain as I process layer upon layer of complexity before my seemingly simple answer comes out as, “Yes” or “No.” As I do so it makes me think about my own variable complexity of decision making.  There were times when I thought I knew everything. Now I know that there was a lot that I didn’t know. Regardless of the topic I am now humbly aware that there are always going to be others who know less than I do and others who have a much deeper understanding than I do.

In January I went to a scientific meeting. I worked to take careful notes to learn as much as I could. One presenter gave a great talk. He reinforced concepts that I already knew but taught me some other things that I didn’t know. His understanding was deeper than mine. There was a time for questions and answers that followed his talk. In this time someone else made some comments that took the understanding to a whole new level. I was blown away by his sophistication and depth of knowledge.

It was a familiar feeling. We went from knee deep water (my understanding) to swimming in 6 feet of water (the presenter’s understanding) to suddenly being in 600 feet of water (the knowledge of the course director who made the comments). His depth of understanding was profound. 

Lesson four was about the multiple levels of knowledge.

Why does this all matter? 

It seems that as I go through life, I have become aware that wisdom means being less rather than more certain of myself and my knowledge. It is not that I know less, but I have become aware of greater levels of complexity and subtlety in each situation. With that knowledge, I realize that there may be even more that I do not yet know.  

In medicine this means that I have learned to embrace the values of humility, sub-specialization, constant learning, and always being willing to ask for help.

In life, the same lessons apply.

Sometimes people can be so certain in themselves that they are willing to harm their relationships rather than admit any uncertainty or that they might be wrong. Sometimes they think they are right and yet they are wrong. A wise person will humbly and routinely admit that they could be wrong.

Sometimes people read a book or an article and suddenly think they understand as much as an expert. It is good to try to do things for yourself but there is also great value and a degree of safety in the skill, knowledge, and experience of a professional. A wise person will seek out a professional when things are hard or not going well.

Sometimes people are convinced that they know everything on a topic but then things don’t turn out like they are supposed to. The truth is that there are always things they don’t know, and even things that they don’t know they don’t know. A wise person walks carefully knowing there might be things they don’t know and looks to others who may have more knowledge than they do.

In most circumstances the truth has multiple layers of complexity or subtlety that go far beyond what people are able to see. What might seem to be a simple black or white question may in truth be very complex. There are always going to be persons who know less and persons who know more than you in each circumstance. A wise person knows this and understands that how they see things may not be the entire story. 

I was seldom wrong when I was single.  No. That is not true. I got things wrong then just as now. I was just not as likely to know it.