Presenting the second-year resident
Now in a magically supervisory capacity.

Said the cattle thief: it's time to take stock.

The intern is a snake devouring its own tail. The second-year resident ("R2" is the quasi-robotic nickname) is still chewing at her tail but is also keeping an eye on the tail-devouring of other snakes, with helpful comments all the while. "Open the maw a little wider! Fangs into the tail like you mean it!" And the hot sand all around, with the Georgia O'Keefe-ish carcasses. And the whistling of passing trains.

The meaning of the allegory: I still sometimes don't feel like I know what I'm doing, even with years and years - I mean, fourteen months - of medical experience under my belt. I know for a fact, more abstract than concrete and more intuitive than learned, that it is better to say "I don't know" than to invent a probably-misleading principle on the basis of limited information. But the latter is what I see people doing all the time around me, and whenever I say "I don't know," I still feel guilty and weak.

Some of this is due to lack of confidence, which will be repleted steadily until my graduation, at the end of my third year of residency. Some of this is due to epistemological uncertainty. I don't know what it means to know about medicine, and at times I'm not sure that everyone else does either.

Let me qualify: there are many models of what it means for a doctor to know something, but none of them covers all the situations that we encounter. "Evidence-based medicine" (one model) is a misnomer, because the "evidence" is population based, while much medicine is done person by person. There are many other jerry-rigged epistemologies, lizards skittering up and down the hospital hallways between the feet of housestaff. "See one, do one, teach one" - sure, but what is "seen" and "done" depend very much on how one is taught. Diagnostics is an epistemological minefield: take into account all your probabilities (Bayesian and otherwise), but you must still walk into a patient's room with at least two or three layers of information and attempted diagnoses made by other people in the hospital who have seen the patient first. Seasoned diagnosticians often cannot explain how they arrive at the correct diagnosis; on the other hand, autopsies (of a previous generation; these days they're rarely done) indicate that diagnoses are wrong about a quarter of the time.

The epistemologic dissonance par excellence is between doctor and patient. The doctor knows the patient's sick, and the patient doesn't believe this at all - or vice versa. The patient knows what's going on in her body, but the doctor needs to do another test to find out - because he says he doesn't know yet. You can say that this is because doctor and patient subscribe to different epistemologies (biomedical vs. traditional, quantitative vs. narrative, or what-have-you), or you can say that neither doctor or patient knows how they know things, or thinks about it much at all. (Meta-epistemology? You came to the right place.)

Now I'm a second-year resident, with more time to think about how I (don't) know what I (don't) know. This is precisely the time when I am supposed to start conveying my knowledge to those one step below me: the interns. (Many of whom, in terms of raw medical facts and figures, know more than I do anyway.) It's appropriate that I don't feel like I know how to do this.

Perhaps I'm thinking about this all wrong. Medicine (or, to term it more appropriately, health/sickness/wellbeing) is based not on knowledge but faith. Induction is a leap. The sun will rise tomorrow because we've seen it done so for our entire lives and heard stories about its constancy. Doctors and patients alike put themselves in the hands of their combined trust: standing at the foot of the mountain or at the door of the hospital.