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CSA and the ‘known unknowns’

Exams and revision can do funny things to a man. I sat the CSA at the end of January and the experience had brought to mind Donald Rumsfeld, US Secretary of State for Defence during the second Iraq War.

I wasn’t thinking of him because I was halfway through a campaign with no end in sight, which was turning out to be a bit more difficult than I had thought. Nor because I had been stripped of my personal possessions, given a number and forced to sit in an airless, featureless room for three hours.

It was because of something he said on February 12, 2002: ‘As we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns — the ones we don’t know we don’t know.’

Donald Rumsfeld got a lot of stick for saying this at the time. Possibly because of what he said or perhaps because of who was saying it. Much as it pains me to agree with Mr Rumsfeld, every time I do an exam I find I have to. Take the CSA as an example. As I logged into for the first time (other online revision aids are available) I was fresh faced, optimistic and confident.

Confidence which soon started to evaporate on starting the questions as I realised I was lost in the land of ‘unknown unknowns’. From there it was a journey to the point where (I think) I at least knew what I didn’t know – I found the online questions were a good way of doing this. The it was a case of trying to reduce the size of the ‘known unknowns’ list.

Confused? I was.

Having just finished my ST2 placement I found I agreed with Mr Rumsfeld even more. His words apply to medicine in general and not just exams. It had started to dawn on me what a huge thing General Practice is. You can’t know everything, and even if were able to get to that point, a lot of what you knew would already be out of date, like painting the Forth Road Bridge – a bit of a depressing thought for someone who likes to know the answer to every question. I suppose one can aim to appreciate what’s on your ‘unknown unknowns’ list, and then to do something about it.

Perhaps another quote from the wordsmith Mr Rumsfeld should have been close at hand: ‘I don’t know what the facts are but somebody’s certainly going to sit down with him and find out what he knows that they may not know, and make sure he knows what they know that he may not know, and that’s a good thing.’

Michael Kilshaw is an ST2, currently living and working in Cheltenham. He can be found on Twitter @docmike79.