The Fraud Police (and other ramblings about self-doubt)

(I realize that is not the most enticing title there is. I don’t have a better one just now, and, as this is about honesty, I can’t really make up a title with no connection to the article:)
Every now and then, as a doctor but I suspect in any other profession, I have moments of “what am I doing here, who the heck gave me permission to do this, why am I in charge?”. I think about it from time to time, but, as I was listening to Amanda Palmer’s The Art of Asking (read it!) yesterday while drawing fern motives on my crutches (random occupation number…. I’ve stopped counting), she happened to mention the exact feeling. She calls it “the fraud police”, the fear that someone might come and call you on your bullshit: how are you qualified to be in this role, to do that or say this? Who gave you the authority?
I constantly go through this. And not necessarily with the -minority – of patients who are angry, for various reasons, about the health system you happen to be working with, or angry about something completely unrelated, or just belligerent, but as a result challenge every decision you make, contradict the advices, etc… Those are fine, and useful: you are reminded you must absolutely stick to evidence, and, usually, you try to go and find why they have lost trust in you or what you represent. They are a sort of welcome detergent, if you like.
The more troubling ones  – maybe not at first glance – are those who come to you in search of absolute certainties. Whatever the question, they don’t want a balanced answer, they don’t want an “I don’t know”, they will trust whatever you say but you have to have an answer.
And, so many times, over and over. you don’t really have it. Whether the question doesn’t have too much consequence, like, “what is the cause of this cough?” (that is, once you’ve eliminated the possible serious causes, often you just know it’s nothing serious, which is not really the greatest possible answer), or “but when am I going to die?” – and again, most of the times, there is no certainty.

I suppose it is a specific kind of “junior-doctor-struggle”, and certainly with experience a lot of the things you didn’t know you’ll learn. But also, as it is an ever evolving science, medicine, but a lot more than that as well, some of the things you’ll learn will be false – and that decay is growing at a faster speed every year, as progresses are made. And a lot of the questions, actually, are not even about “evidence-based” concepts. Those are the easy ones: either you know the last guideline or you don’t, and if you don’t you should absolutely and every time say “I don’t know, but I’ll check”; and check, even if it means that on the spot right there you’ll look like an incompetent fool, instead of the competent professional you are supposed to be, even if, by doing so, you are actually acting as a competent professional should. But that is another subject altogether, the pressure of “never making any mistake” which is demanded on us (again, absolutely not limited to doctors or health professionals, there’s a great video there about it).
So the harder questions, the non-medical ones, the philosophical ones. The ones no one probably has a definitive answer to, but that you are somehow expected to answer. Those are the moments when I mostly feel like “the fraud police” is going to come knocking. (Even if that thought also pops out randomly, when no one is asking questions:  often when you feel you’re not being supervised enough). Because I’ve been asked, countlessly: Do you think he suffered? Do you think I will suffer?, How many days, doctor?, What happens after? Can he/she actually hear us (while in a coma)? what do you think this dream means? Do you think this illness happened for a reason? why me? why now? why not somebody else? All my friends behave the same way (smoke, drink, fill in whatever you want) and they don’t have that…and others, sometimes weird and unexpected, sometimes trivial – but you still don’t know.
At those times, I expect it would be so practical to have a sound belief system to base your answers on: to be a preacher, of any religion. Because at least you have a canvas to build on, and the (alleged) authority on that subject. – Though, of course, they must also feel the same, I know – I, as a medical professional, am not supposed to have a pre-existing belief system. I am supposed to be scientific, and human. But  I sometimes feel like, despite not having the all-knowing-book, I have to go to the pulpit and find some certainty, sometimes any certainty, and it has to be said with the conviction of a preach. I don’t do well on convictions. I like doubts, I don’t mind them for myself, at least in those kind of questions. So find answers for others always leaves me with this feeling of ” who the heck gave you the authority?”.
Yet, when I think about it, I feel it is probably better that way. Because the real danger, here, is to not feel like the fraud police might come any more, to feel certain of what you say, whatever it is. That’s when you loose the assumption of “I might be wrong” which is essential to progressing. That’s when you stop learning. That’s when you make the biggest mistake. Knowing me, I doubt, even with years of experience, I’ll ever feel like the fraud police has gone, or I hope I never will. I will still be unsettled by many questions, many doubts. I will still often feel like I’m not up to the job, not qualified enough. You probably just have to live with the fraud police, and be thankful for its reminder: you will always have more to learn, so try to find the best possible answer you have, at that moment, always admit you can be wrong, and often are, never be afraid to say “I don’t know”, even when it’s not what one might want to hear.


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