Home > Education, General, Rants and Raves > You Know Nothing Jon Snow

You Know Nothing Jon Snow

As a physician, I occasionally encounter patients who feel like they know a great deal more about medicine than they actually do.  Sometimes its a family member of a patient.     Occasionally they are right, in that they have a particular cache of knowledge about a particular condition that surpasses me.  In those circumstances, such patients or family members are able to augment their care.   Far more often, however, their expertise is far less than they think.

For example, I once cared for someone who clearly needed a blood transfusion.  A family member was in strong opposition, mostly because that family member was Jehovah Witness, even though the patient was not.   That family member presented all kinds of information about alternatives to blood transfusion, and clearly right from a pamphlet they had read.  At a fundamental level, said family member believed that there was always an alternative to blood transfusion and it was never actually necessary.

I was benefited in this situation by seeing in my patient’s face that she found her own family member to be a little overbearing and ridiculous.  Armed by that knowledge, I smiled and said “So lets be real here… you don’t have any real background in what you are talking about, right?”  I got a smile back, so I continued “so let me explain what everything you just told me actually means, and then why it doesn’t apply in this situation.”  Ultimately the family member was satisfied, and the blood continued to run.

This situation was an example of a common rule of knowledge, and a person’s self perception of that knowledge.   That rule is this:

The less you know, the more you think you know.

And the corollary:

The more you know, the more you realize how little you know.

The family member had read a pamphlet from the church on why the do not accept blood, and all the things that can be done to prevent blood transfusion.  So having read that, but having no real knowledge to give that information context, she developed a very inflated concept of her knowledge.

This idea has been shown among college students as well.   In a psychology experiment, students are asked to take a test on a subject.  Before they take said test, they are asked to self assess how much they know about said topic.  The results invariably come out showing this:

People that know nothing realize they know nothing.

People that know just a little think they know a great deal.

People that have a medium amount of knowledge tend to know their knowledge is medium.

People that have a high amount of knowledge believe they are average to below average.

And perhaps in the perfect inverse, those that have extreme knowledge realize they have extreme knowledge.

So why is this?  I have a theory.

I think that we assess our own knowledge by comparing what we actually know to what we believe is knowable.   If we know everything that we think is knowable, then by our own assessment we are expert.  If we know what we know but also know that there is an incredible amount of information out there that we do not know, then we realize that we know very little.

The nature of education is such that we are exposed to a tremendous amount of potential knowledge, but actually only learn a subset of that knowledge.  In fact, I would estimate that for every quanta of knowledge that we gain, we become aware of perhaps ten times as many quanta that we do not actually gain.  For example, as a physician I have significant mastery of the area in which I specialize, but through the course of reaching that mastery I have been exposed to orders of magnitude more information over which I did not attain mastery.  Therefore, as we learn, our ratio of knowledge to our awareness of potential knowledge is constantly decreasing, and thus our assessment of our own expertise is actually falling as we become more expert.

Sometimes this inverse relationship goes in cycles.  I experienced this myself over the course of my medical education.  While in college, I studied as an Emergency Medical Technician, and eventually reached the middle grade of EMT-Intermediate.  I worked in the emergency department for several years during that time, and indeed picked up a tremendous amount of medical information through that experience.  To my great self-embarrassment, however, I can honestly say that it occurred to me at that time that if there had been no emergency physician present, I could have run that emergency department.   I now know, however, that at that time in my life I knew almost nothing.  My mind at that time was filled with a lot of little facts and little relationships, but I had no real idea how those facts connected together.   While I might have been able to deal with certain situations, I had no way to deal with a new situation or work out something complex.  I simply lacked the education to realize how little I actually knew

Upon entering medical school, it took me about 24 hours to figure this out.  I was overwhelmed with potential knowledge, and once again felt completely ignorant.  But over the four years of medical school, my self assessment again started to rise.  I had learned a tremendous amount about a wide variety of medical topics, and had started to mine the depths of my view of the medical world.  I was again an expert.

Then I became an intern, and now faced with the depths of my specialty, which previously I had only learned at a superficial level, once again I realized I knew very little.  By the time I was a chief resident, full of knowledge but lacking ultimate responsibility, I was pretty sure of my self once again.

As a young attending, I was pretty sure I could handle anything that came my way.  And I did indeed have substantial expertise.  But by six years later, continuing to grow and learn, I knew I didn’t know enough, and that I wasn’t as good a surgeon as I wanted to be.  This ultimately led me to fellowship, where I not only learned but again expanded my awareness of what I did not know.

And now, with four years of medical school, four years of residency, six years of practice, and a year of fellowship, I have a lot of expertise.  But I’m also aware of how much there is out there that I don’t understand.

But this is good.  It keeps me reading, and hopefully keeps me humble, which some may said would be difficult.  And I have no doubt that in ten years I will be able to look back on my current self and muse on how little I actually knew, and how I thought I knew so much.

And so, to the lady that wants to teach me all about blood transfusion from the pamphlet her church gave her, I can only laugh.    I too once thought I knew it all, but it was only because I knew almost nothing.


To those who have not experienced the wonder that is Game of Thrones, both in book and television form, Jon Snow was a man who grew up in the North of Westeros, and per his ancestry was descendent of the original people of The North.  Upon actually coming north of The Wall, he meets a woman who had lived there her entire life.   She constantly reminds him that he only knows enough about The North to think he knows far more than he actually does.

  1. September 8, 2012 at 8:43 am

    This is true of so many things in life! I certainly have felt that way as a lactation consultant. I had an OB/GYN ask me yesterday to tell her “everything [she] needed to know about breastfeeding in an hour” – she was clearly a great doctor who cared about her patients and wanted to be able to help them if they asked her about basic breastfeeding problems. I suggested a couple books for her to read, and invited her to e-mail me with her most frequently asked questions so I could suggest ways for her to deal with them.

    But I also said, “You probably have patients who have someone who practices more general medicine give them advice or treatment for a gynecological problem, and it frustrates you because the patient does not get the most expert or up-to-date care. I feel the same way when a pediatrician or a midwife or an OB who is not a lactation consultant tries to help someone who is having breastfeeding trouble.” Because those people interact a little with breastfeeding, they think they know more than they do; and they can’t imagine what else a person would need to do or think of. I know because I’ve been there, when I was at the “EMT” level of breastfeeding training. I also realized how ignorant I had been within a couple weeks of starting IBCLC training. Two years into practicing as an IBCLC I am still stumbling into whole new areas I am newly ignorant of! And like your experiences, I’m sure ten years from now I’ll think the same.

    I suggested to this OB that the most useful thing I could teach her was not just what to say in common situations, but also where to refer her patients for different kinds of problems. I didn’t want the result of my hour of teaching to be that she went from knowing she knew nothing to thinking she knew everything. I hope by relating this back to her own experience, she’ll understand why she shouldn’t try to go it alone in terms of helping her patients, who might think “my doctor helped me, so if I’m still having problems I guess I just have to give up”.


  2. Franny Meritt
    September 8, 2012 at 8:44 am

    Seeing this clearly in the residents I am teaching. I am a nurse midwife in a family medicine clinic that offers both a 2 year FP rural tract training or an extra 1 month OB rotation for Family Medicine residents training elsewhere. With my 1 month FP’s — their experience is completely from ‘unit sitting’ in a much larger hospital and the only ‘prenatal care’ they come to me with is what they’ve read and triage. I know they are frustrated when I make them observe for a day or two, but at the same time, they have vast deficits in risk assessment, anticipatory guidance, expectant management and frankly, bedside manner. Would love a tutorial on how the self conscious mid level practitioner can help prune the resident ego!


    • September 8, 2012 at 8:56 am

      And we see it as well in reverse, where the mid level practitioner knows enough to be sure that they could replace the physician, when really they do not.


  3. Livia
    September 13, 2012 at 12:04 am

    I fully agree that Rebecca that this happens in all aspects of life; it just probably seems more dangerous in medicine. As an increasingly well-read patient with a science background I find it’s very useful to read on what you may or may not have, as it applies to many in the medical profession, too, alas. I do understand there is an immense lot to know, and that they deal with lots of people whose “knowledge” is totally baseless. Kudos to you for dealing with the blood transfusion issue so well!


  4. September 22, 2012 at 7:28 am

    I understand a doctor’s hesitation to listen to patients who ‘think they know more’ than they do. And sometimes, as you admitted, they really do know *something*, albeit probably not everything, about what they’re talking about. I do think it’s important to listen to a patient’s concerns about things and not brush them off or make them feel stupid (not that you’re doing that), and many times during appointments it makes for good conversation about my care.

    I have, unfortunately, run into at least one physician (a physician’s assistant, really) who works for my primary care doctor that is alarmist and slightly inept, I feel. She has misdiagnosed me on several occasions, including given me antibiotics when she suspected I had mono. Had in sunken in sooner, I would have asked her, “What good, exactly, is this going to do?” Now I have been facing a long, drawn-out illness that I feel is misdiagnosed after initially seeing her, and while I don’t want to seem like a hypochondriac, feel that there has to be more to it besides what she initially told me. It is frustrating because I realize I’m no doctor, but through discriminate research have learned that perhaps she was completely wrong. Time will tell.


  5. September 22, 2012 at 7:35 am

    What a great and insightful post! The most helpful attitude I bring to the table as a new learner in medicine is, “What can I learn here?” If I always have a disposition and attitude that there’s “always more to learn” and never stop searching for answers to questions and then searching for new questions to ask, then I feel confident that I will be effective wherever I am at. How helpful to know this humbling posture early on! How dangerous, however, to encounter those in medicine who do NOT have this mindset. Not only is a prideful attitude unattractive, it’s dangerous!


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