"I don't know"

Posted by Bernie Marini at Tuesday, November 22, 2011

To remind myself to post a blog this rotation, I simply put "I don't know" in the subject heading, and I bookmarked it. I didn't have a great idea or theme for a post at that point in the rotation. Nothing great came to mind. But then, I realized "I don't know" is actually a perfect theme.

"I don't know."

Those are the three very powerful words. To me, they evoke a wide range of emotions - fear, frustration, embarrassment, curiosity. As P4's, we dread having to utter these words on rotation. However, the best rotations are those in which those three words are the most frequent...

For example, I have just finished my rotation on the infectious disease (ID) service at U of M, and for once, I went into this rotation very confident. My rotation with Dr. Frame on the BMT unit gave me extensive practice in ID; I followed patients with a diverse array of infections - BK cystitis, fusariosis, invasive aspergillosis, etc.. So, armed with my white coat pockets stuffed with my trusty bug/drug list, my "blue book", and various fungal charts, I was ready to tackle ID head on...and it hit me, hard (like a Michigan linebacker!).

There was so much in ID that I didn't know, and having a challenging and extremely knowledgeable preceptor like Dr. Carver made that apparent quickly. Sure, I had a little knowledge of basic things like the adverse effects and drug interactions with azole antifungals, pharmacokinetic dosing of vanco and aminoglycosides, but I was quickly getting questions like:

• Should colistin be dosed on ideal body weight or total body weight?
• If we MUST to use bactrim in renal failure (although the package insert says not to), how should we dose it?
• Can we use tigecycline in a cystic fibrosis patient? If so, how much should we give?

Having difficult questions such as these thrown out on a consistent basis pushes you to the next level. I worked hard each day to search the literature for answers to my difficult questions, all the while following and assessing the drug therapy of a large number of patients. This is how the best rotations go. At the start, things are a bit overwhelming. You're clearly not an expert in the subject. But then you adapt. You start to think ahead. Anticipate. Think, "what questions will I get?" "If I was the attending or preceptor, what else would I need to know?" You start thinking like a pharmacist.

Unless you're a genius, we've all had "I don't know" moments on rotations. And although we dread the feeling of unknown and the embarrassment of ignorance, it's these experiences that make us better pharmacists and better people. Sure it's corny, but it's true: unless we know that we don't know, we can't know...anything. Wait, what? You get the point.