What to Do When You Don't Know the Answer as a Doctor
What to do when you don't know the answer as a doctor
Do three things in order. Say it out loud: "I don't know" and state what you do know. Sort the kind of not knowing, is it a missing fact, a forgotten concept, or a risk you can't quantify. Then either look it up on the spot or escalate immediately.
Think process, not trivia or heroics.
Picture the ward round, consultant at the bed end asks about an overnight change, the team waits while the clock in your head gets loud.
Your fear of looking foolish pulls one way. The risk to the patient pulls the other, and the patient wins every time.
Sorting the not knowing takes seconds.
- "I don't know, here is what I know and what I need to check" covers missing data you can gather fast.
- "I can't recall the exact rule but I can reason it out" covers memory gaps.
- "this could be unsafe without senior input" flags a true red line.
If you want a longer primer on day one mechanics, see getting through foundation year one.
The two kinds of not knowing
The skill in what to do when you don't know the answer as a doctor is sorting the kind of not knowing you're in. One can wait, the other cannot. Ask one question, plain and out loud: does this gap change what happens in the next hour?
- Factual gap, won't change next hour What it means: Park it, look it up, set a time · What you say: "I don't know yet. It can wait an hour while I check, then I'll update you at X."
- Uncertainty that may change safety or choices What it means: Can't wait, the not knowing is the problem · What you say: "I don't know what this is, and that's why I'm calling now. These features worry me, the uncertainty affects the next hour."
The patient is a 72-year-old man, an AI patient from Diagnosica's case library. You're told, "The pain came on SUDDENLY about SIX HOURS ago, is CENTRAL, CONSTANT and SEVERE, and has not eased at all." Vitals are heart rate 112 and blood pressure 106/64.
On questioning, you're told, "The pain is EXCRUCIATING but pressing on his abdomen hurts surprisingly little, it is SOFT with only mild tenderness and NO guarding or rebound."
That discordance is the point. The case states, "This discordance IS the diagnosis: PAIN OUT OF PROPORTION TO THE EXAMINATION FINDINGS." Waiting for late peritonism is why this gets missed, which is exactly where uncertainty turns into harm.
The words that actually work
Ward round, in front of everyone: "I don't know. My thinking is X because of Y, but I haven't confirmed Z. Can I check and report back shortly?"
Patient or relative: "I don't know right now, and I don't want to guess. I'll check with the team and come back to you today."
Nurse on the phone: "I don't know yet. Give me the headline, I'll review the notes now and call you back, and if I'm still unsure I'll loop in the reg."
The bluff you're tempted to use: "It's fine, it's definitely X." The honest version: "I'm not certain. My hunch is X because of Y, but it could be Z. I'd like to run it past a senior before we act."
In the never say I don't know thread, three replies are worth keeping. "rule #1: never lie about a patient to your intern/resident/attending/whatever even if that means saying 'i don't know'." "I figure it is better to keep my mouth shut and let somebody think that I might be an idiot than ramble around pretending to know an answer and PROVING that I am one." "If you don't know the answer - then say 'I don't know, but I'll look it up'."
On ward rounds, Alexander Tam's FY1 guide on Mind The Bleep ward rounds says: "Don't be scared to ask your seniors if the findings are unclear" and "It is important you ask your seniors for support or to slow down as you need."
Rehearse with an AI patient: Diagnosica's free tier gives you one case a week with an AI patient, and you can run a case free.
How to escalate when not knowing is the reason you're calling
The hardest call is when you can't say what it is. Make the call anyway. Not knowing is the report, and SBAR already has a slot for uncertainty. Say it out loud.
SBAR stands for Situation, Background, Assessment, Recommendation, and the Institute for Healthcare Improvement calls it "an easy-to-remember, concrete communication mechanism for framing any conversation, especially critical ones, requiring a clinician's immediate attention and action." Here is the SBAR handover framework.
- Situation, one sentence on why you're calling and what worries you now. Name the patient, plain-words problem, and time course, and if the diagnosis is unknown, say what you do know and what feels off.
- Background, only data that change risk in the next hour. Give timings, fresh observations, any single fact that shifts your gut, leave out the rest, and if you lack background, say you don't have it yet.
- Assessment, where uncertainty lives. Say you don't know, then share the pattern you see or the mismatch that scares you, and note that pain out of proportion can be the finding.
- Recommendation, ask for a person and a time frame. If it's now, say now, and name where you are and stay with the patient.
This is the same 72-year-old from earlier in the post.
"This is the FY1 on the ward. Situation, I'm calling about a 72-year-old man with six hours of sudden, constant, severe central abdominal pain. His abdomen is soft with only mild tenderness. Heart rate 112, blood pressure 106 over 64. Background, that's all I have so far. Assessment, I don't know what this is, and the pain feels out of proportion to these findings. Recommendation, could you come and see him now please, I'm at his bedside."
It uses the same muscle as the bleep you cannot answer.
Sometimes you don't know because nobody asked
The second kind of not knowing is silent, the answer existed but the question never left your mouth.
Take the case Back pain and leg weakness, 45M, another AI patient from the same Diagnosica library. He's a stoical working man, plays down symptoms, visibly uncomfortable and embarrassed about the bladder and saddle symptoms.
He offers you a tidy story. He thinks he has just aggravated a slipped disc and that the codeine is bunging up his bladder. The case's own teaching line spells the trap. Patients under-report these symptoms, they are embarrassing, and urinary problems are commonly blamed on opioids.
Here, six facts are marked as red flags the learner must elicit, more than any other case named in this post. Several only surface if you ask outright. He has NUMBNESS between the legs and around the back passage, he noticed it when wiping. He has been UNABLE TO PASS URINE properly for two days, only dribbling, with a constant feeling of fullness. He's had new erectile difficulty over the past two days.
If you never ask, you leave with his false explanation and no signal that it's false. Worse than knowing you're stuck.
The case's own scoring is blunt. Not asking those red flag questions is a 15 point deduction, and accepting the patient's own explanation for his urinary symptoms without checking is another 15 point deduction.
The case's marking rewards exactly the opposite behaviour. It earns points for sensitively but EXPLICITLY asking about saddle numbness, bladder emptying, bowel control and sexual function in a man who minimises and is embarrassed.
You can practise saying the gaps out loud here, thinking out loud on shift.
Reasoning out loud beats having the answer
Start by reasoning out loud. Seniors aren't testing your trivia buffer, they're listening for what you noticed, what it could be, what would change your mind, and what you plan to do about the not knowing.
This starts absurdly early. There's a pre-med asking this about interview questions they can't answer, and it's all process, not clinical. The replies boiled down to "walk the interviewer...through the logic you would use to develop an answer". Another reply said, "I can't say I've ever thought about that before. Pause, breath, think."
A doctor even wrote about it years ago. Alex Lickerman, MD, published a 2010 physician essay on exactly this on 22 February 2010, and from what I can tell it's still one of the few honest things written on it.
On the ward, the consultant or registrar hears how you hold uncertainty. Say it cleanly and the room relaxes. They can spot the missing question in your history, steer you to the chart for a prior result, and stop you spinning on a hunch.
That's a skill, not a vibe. It needs reps, because delivering your thinking calmly in front of a senior while a patient and a clock exist feels different to writing it in notes. Most of us only practise it in that room, and there's a cost to being wrong out loud.
Where to practise not knowing
Diagnosica lets you practise not knowing safely, then defend your reasoning to an AI senior after you commit to a diagnosis and plan. There is no physical examination practice, findings are told to you rather than elicited, and the AI patient is always disclosed as AI. "It doesn't give advice about real patients, and it's not a diagnostic system. Treat every output as educational."
It's live and early, so you may hit a rough edge now and then; free is one case a week, Standard is $29 a month or $249 a year, and UK cards see 22 pounds a month or 189 pounds a year. The library is 74 cases across 14 specialties in three difficulty bands, and every one of them is written and signed off by a doctor.
You'll get asked things like: "A 72-year-old has six hours of severe central abdominal pain but a soft, barely tender abdomen, what does that mismatch mean to you?" "His lactate and CRP come back normal early, are you reassured? Why not?" "A 45-year-old has three weeks of back pain and now weak legs, what specific questions must you ask before he leaves the room?"
It mirrors the registrar's move, and you can say, "I don't know, here's what I'd do about it." You reason out loud and get pressed.
You can start a case free when you want to see how it feels.
Educational use only, not medical advice. AI-generated; verify clinically against primary sources.
Clinical review pending.
