On not knowing

I've been reading Kateri's post about a woman who developed breastfeeding problems because her doctors didn't know enough about breastfeeding and thus gave her poor advice.

That one sentence could describe so many, many, many stories that I've read out there. As soon as you start finding out anything about breastfeeding, you start to hear the horror stories about the sheer ignorance in the medical profession about anything breastfeeding-related. This particular woman had an unusual problem - there aren't many women trying to breastfeed after breast reductions. But there are thousands upon thousands of women who have been given equally poor advice about much more common problems, problems that anyone who has anything to do with lactating women should damn well know something about.
Kateri laments this ignorance, and quite rightly so. It is execrable. Do you know how much teaching I've had on the topic of breastfeeding I've had in my career? In five years in medical school, a year as a junior paediatrician, a year of more specialist general practice training? None. That's how much. And it wouldn't even take much, for God's sake. Just one lecture in medical school would cover enough of the basics for what we need to be aware of as doctors. We could easily have spared that much time from learning about Krebs' cycle and the nine causes of clubbing and all the other obscure things that you never need once qualified. But I doubt if it ever occurred to the people designing the syllabus. Same thing in the postgraduate training - we had a lot of say in what topics we got taught about as trainee doctors, but none of us asked for a talk on breastfeeding because it never occurred to any of us.

Kateri thinks that this is because it's seen as unimportant - if breastfeeding doesn't work out, what's the big deal? Just use formula. I have certainly heard stories of women encountering this attitude, which I will not recount here due to having insufficient time and tooth enamel to spare on them. But I also think that a lot of it is that people don't even know what they don't know. If you don't know anything about breastfeeding, it never occurs to you that it might prove difficult for some people, that there might be things that doctors need to know about it, even if it's just stuff like how to treat thrush and that nipple pain is not normal and indicates a problem. So, nobody thinks of putting it in the syllabus.

But there's a deeper issue here that Kateri didn't comment on, but that springs out at me because I've been through medical training. It's the fact that, as junior doctors, we are discouraged from admitting that we don't know something and trying to learn more.

At least - I put that in the present tense, and I would love to feel that I'm wrong in doing so. It'll be eleven years this year since I graduated, and that's actually quite a long time in the fast-moving field of medical education, so maybe attitudes are changing. Maybe, these days, students who ask their consultants questions are less likely to be met with a frown and a growl of "You should know that by now!" Maybe more consultants are finally catching on to the fact that students who ask about something know perfectly well that they should know it, and that's why they're taking the sensible step of asking the person who is, after all, meant to be teaching them. Maybe the people doing the teaching are realising that questions should be met with answers rather than accusations.

I hope that's happening, and I think that, little by little, it probably is. I think that the underlying culture - the attitude that lack of knowledge is something so embarrassing and shameful that hiding it must take priority over trying to correct it - is changing. But I do know that old habits die hard, and that it may take a while before that attitude disappears altogether among some of the older-school hospital consultants who teach students and junior doctors as part of their job. There are still too many doctors out there who have learned to guess, to bluff, to do what they can to hide any lack of knowledge rather than admitting it and approaching someone who can put it right.

And I think it's that attitude that is the root cause of the problems Kateri's acquaintance had. I do actually think that it's perfectly reasonable for your average doctor not to know anything about breastfeeding after reduction. It's an unusual and specialised problem that a doctor is not going to encounter very often, and believe you me, there is no shortage of more common things that we need to know about. But what is not reasonable is that none of the doctors that this woman saw felt able to say to her "You know, I actually don't have a clue about that. Let me read up on it, or find somebody who does and ask their advice about it, and I'll get back to you."