The Power of Not Knowing

Dr. Akram Boutros joined The MetroHealth System as President and Chief Executive Officer in June 2013. He serves as the leader of The MetroHealth System and is its primary public representative, reporting to the MetroHealth Board of Trustees. He works in partnership with the Board to ensure that the organization fulfills its mission and creates strategies that ensure its future success.

Dr. Boutros has more than 20 years of leadership experience in large community hospitals, specialty hospitals and academic medical centers. Most recently, he was President of BusinessFirst Healthcare Solutions, a health care advisory firm focused on clinical  transformation, operational turnarounds and emerging health delivery and reimbursement models. Dr. Boutros previously served as Executive Vice President and Chief Administrative Officer of St. Francis Hospital – The Heart Center in Roslyn, New York, and as  executive Vice President, Chief Medical Officer and Chief Operating Officer of South Nassau Hospital in Oceanside, New York. An internist, Dr. Boutros received his Doctor of Medicine from the State University of New York Health Sciences Center at Brooklyn. He is a graduate of Harvard Business School’s Advanced Management Program and is a recognized thought leader in management systems.

Dr. Boutros also serves on the boards of the Greater Cleveland Partnership, United Way of Greater Cleveland, the Cuyahoga Community College Foundation and the Cleveland Ballet. Most recently, he served as Chair of the American Heart Association 2015 Cleveland Heart Ball, the most successful in the city’s history. He has been named to Power 150 by Crain’s Cleveland Business, Power 100 by Inside Business Magazine and EY 2015 Entrepreneur of the Year for Community Impact in Northeast Ohio.

Twenty-eight years ago, I sat where you sat, thought what you thought, and asked myself, is medical school really over? 

Will I be a good doctor?
What will the future of health care look like?
Where do I fit into that future?
Will I survive those coming changes?

My answer to each of those questions was the same: I don’t know. No one knows. But I do know a few things after nearly 30 years in this crazy profession that you are a “flip of a tassel” away from entering. I learned the first one when I was a little older than most of you.

I was in my second year of residency, near the end of one of my every-third-night ICU rotations. Exhausted, I had fallen into a deep sleep when a nurse woke me to tell me a patient who was septic – filled with infection – had become acidotic – possessing a level of acid in bodily fluids so high, it can kill you. Still foggy, I sat up in bed and said, “Give her an amp of bicarb.” It was a reflexive response. I knew bicarbonate, a base, would correct the acidosis. And as soon as I said it, I laid my head down and fell back asleep.

Five minutes later I woke again, covered in cold sweat. I’m not just using that phrase here. I was in a cold sweat. Somewhere in my subconscious, I remembered that this woman, this septic patient, also had end-stage renal disease. Her kidneys had failed. And she was retaining so much fluid it was straining her heart. As many of you know, bicarb is short for sodium bicarbonate and sodium is salt and that salt would make her retain even more fluid. I had just ordered a remedy that could kill her.

Fully awake, heart racing, I ran to her room. I was too late. The nurse had followed my orders. What I experienced next was panic. My stomach churned. My heart raced even harder. Will she die? God, I hope not. How am I going to fix this? Who should I tell? What should I do? Is this the end of my career? What the hell is wrong with me?

No one likes to risk their reputation, to claim they made a mistake, especially a potentially deadly one. But at 2 a.m., I called my ICU attending. I called the patient’s attending. I called the nursing supervisor. I called the renal fellow. And I told them all the same thing: “I screwed up.”

Nobody yelled. And nobody fired me. Instead, together, we agreed to assemble a team to perform ultrafiltration to draw off the fluid – before it did its damage. It worked. The patient made it. She survived. Not because of me. Because of the team that gathered around me. They all wanted her to live. And they all wanted me to succeed.

Everybody wants you to succeed, too. That’s the first thing I want to leave you with today, one of the things I hope you’ll never forget: We are ALL rooting for you. Your teachers are rooting for you. Your bosses are rooting for you. The institution you work for is rooting for you. So are your patients, your family, your friends, and your spouse. ALL of us. We love you. We need you. We want you to be happy, confident, good at what you do, and in love with it. We want that for all kinds of reasons.

One of those is that someday we may need you to take our pain away, to help us walk again, to give us back enough energy to play with our kids or grandkids, to save our lives. Close your eyes now, for just a minute, and picture in your mind, the world of people who are behind you. So many of them are here today. Imagine them, in the stands, on their feet, cheering you on. And whenever you find yourself in a tough situation, come back to that image. Imagine everyone who cares about you cheering you on. Because we are.

I have another message today. This one comes from a different moment early in my career, another one I’ll never forget. It was July 1, 1988: the first day of my internship, and my first day as a doctor. I was on call and because my last name begins with B, I got the first admission to internal medicine: a transfer from another hospital. When I walked into the room in the ED, a middle-aged woman was sitting up in bed, dressed in a hospital gown, looking very anxious. I began with the textbook question: “What brought you to the hospital?”

“They think I have Churg-Strauss vasculitis,” she said.

I remembered that I’d studied the disease awhile back. I remembered that it was serious. But I couldn’t remember what it was or what organ system it affected. In fact, I couldn’t remember anything else about it. I felt unprepared, like I had nothing to offer, that I was useless.

But I kept going. I thought, alright Akram, just keep asking questions – as many questions as possible – and maybe you’ll get a clue. If that doesn’t work, try the ‘fake it ‘til you make it’ method. Maybe that works for doctors, too. I took a detailed history, asking questions about diseases in her family and what medications she was on. As I was wrapping up, she looked at me and said “So what do you think, Doc?”

I stopped and thought for a few seconds. I thought about saying “Oh, we’ll have to see,” or “We need to run some tests” or something else that would make me sound like I really knew what was going on. But when I looked at her again, I saw how concerned she was. And different words popped out of my mouth.

“I don’t know.”

I was embarrassed to admit it. But, to my surprise, she wasn’t angry or afraid. She chose understanding instead. Immediately, I promised her that I would learn as much as I could about Churg-Strauss before the next day. I told her that every day she was there, in the hospital, I would do my very best to gain the knowledge I needed to take good care of her.

She died. But it was 13 years later. And every one of those 13 years, she was my patient. During those years, she told me, more than once, that the reason she trusted me with her life was because I had been honest with her. That honesty humanized me. Those three little words – “I don’t know” – made her believe in me.

I kept my promise to her. I sought out those who knew more about her deadly vasculitis than I did. And I asked them to teach me what they knew, to be my partners in her care. Together, we gave her 13 years she might never have had.

“I don’t know.” Don’t ever be afraid of those words. They are the start of something beautiful. And they’re a reminder, every day, that we are doctors, not Supermen or Superwomen.

In America, we celebrate the Lone Ranger. And what we really need to celebrate is the Fantastic Four, no The Justice League. Sometimes – no, often – you need the Elongated Man, the Red Tornado and Wonder Woman to get the job done. Having Martian
Manhunter with his genius intellect and regenerative healing helps, too.

Remember: You don’t have to be able to do it all or know everything. Your teachers don’t expect you to. Your colleagues don’t expect you to. And your patients don’t expect you to. The only person who insists that you have all the answers is you.

Say “I don’t know.” It’s one of the smartest, bravest things you can say. It will take the pressure off. People will trust you. Nobody believes a know-it-all. Amazing things will happen when you say “I don’t know.”

I think the late poet Wislawa Szymborska said it best. In her 1997 speech accepting the Nobel Prize for literature, she talked about why she loved that three-word phrase:

“It’s small,” she said, “but it flies on mighty wings. It expands our lives to include the spaces within us as well as those outer expanses in which our tiny Earth hangs suspended. If Isaac Newton had never said to himself “I don’t know,” the apples in his little orchard might have dropped to the ground like hailstones and at best he would have stooped to pick them up and gobble them with gusto. Had my compatriot Marie Sklodowska-Curie never said to herself “I don’t know,” she probably would have wound up teaching chemistry at some private high school for young ladies from good families, and would have ended her days performing this otherwise perfectly  respectable job. But she kept on saying “I don’t know,” and these words led her, not just once but twice, to Stockholm, where restless,
questing spirits are occasionally rewarded with the Nobel Prize.”

Be restless, questing spirits. Explore, always. Exploring leads to discovery, and discovery to whole new worlds. And those worlds to the theory of radioactivity, the laws of motion and great things we never imagined were possible, things that make the world a better place.

That is why you – with this beautiful knowledge you’ve spent years acquiring – are here. You are here to make your patients better, your communities better, and the world better. And you do that by being restless, questing spirits. You do that by saying “I don’t
know.” Those three words are the start of something beautiful. THAT is one thing I know for sure.

 

Akram Boutros, MD
Northeast Ohio Medical University
Commencement Address

The Medical Commencement Archive Volume 3, 2016

 

 

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