Listen to JCO's Art of Oncology article, "The Power of "I Don't Know" by Dr. Sondos Zayed, who is a radiation oncologist at The Ottawa Hospital and an assistant professor at the University of Ottawa, Canada. The article is followed by an interview with Zayed and host Dr. Mikkael Sekeres. Dr Zayed shares a reflection on the unexpected power of saying "I don't know," and how honest uncertainty can deepen trust, guide care and create space for what truly matters in oncology. TRANSCRIPT Narrator: The Power of "I Don't Know", Sondos, Zayed, MD, MPH, FRCPC Mikkael Sekeres: Welcome back to JCO's Cancer Stories: The Art of Oncology. This ASCO podcast features intimate narratives and perspectives from authors exploring their experiences in oncology. I'm your host, Mikkael Sekeres. I'm Professor of Medicine and Chief of the Division of Hematology at the Sylvester Comprehensive Cancer Center, University of Miami. Joining us today is Dr. Sondos Zayed, a radiation oncologist at the Ottawa Hospital and Assistant Professor at the University of Ottawa, Canada, to discuss her Journal of Clinical Oncology article, "The Power of I Don't Know." At the time of this recording, our guest has no disclosures. She and I have agreed to address each other by first names. Sondos, thank you for contributing to the Journal of Clinical Oncology, and what a pleasure it is to have you join us to discuss your article. Dr. Sondos Zayed: Thank you so much for having me. It's a privilege. Mikkael Sekeres: Can you tell us a little bit about yourself? Where are you from? And walk us through your career up to this point. Dr. Sondos Zayed: Yeah, oh my goodness. So it seems like such a long road and yet so many years left in my career, hopefully. You know, I'm Canadian, and I had the opportunity to grow up in Montreal, which was wonderful, and I went to McGill Medical School, and then after that pursued Radiation Oncology Residency at Western University. And following that I did a fellowship specializing in GI and CNS malignancies with MR-Linac technology in Toronto, and eventually landed in Ottawa, where right now I'm a radiation oncologist treating GI and CNS malignancies and an Assistant Professor at the University of Ottawa. Mikkael Sekeres: That's fantastic. How far are you out of training? Dr. Sondos Zayed: Well, this would be officially my second year essentially as an independent radiation oncologist. Mikkael Sekeres: Wonderful. And I'm curious, what drew you to radiation oncology? Dr. Sondos Zayed: I always say that it was meant to be. And the reason being, when I was in medical school at McGill, they parachuted us out into very niche specialties that we wouldn't otherwise have exposure to. And essentially the way that they would do that is they'd send us an email and say, you know, "Show up at this place, at this location. Here's attached a PowerPoint, just review it before you go." And I get this email and the PowerPoint is talking about, you know, photons and electrons, linear accelerators. And I'm like, "I have no idea what's going on. This is so confusing." I thought I was in medicine. And so I do follow the instructions and I was so lucky that I had such a wonderful supervisor, and he showed me the machines and I saw the coolest cases that day, and it was just such a wonderful experience and the most captivating. And so I just kept on wanting to go back. And the rest is literally history. The really, really fascinating thing about radiation oncology is that it's the mix of physics, it's a mix of like technology, and at the same time there's the medicine and the clinical aspect of it. And there's obviously the privilege to be able to support patients on their most vulnerable journeys with their cancer diagnosis and treatment, et cetera. And so it's a mix of the most interesting things all around and I felt like the best fit for me. Mikkael Sekeres: Well, your passion for it is absolutely palpable. It's really fun to hear the excitement in your voice. Isn't it interesting how one mentor can make the difference in the career path we choose? Dr. Sondos Zayed: Absolutely. Never underestimate the impact they can have on any single trainee at any point in time. It really does turn things around for many people, and it can inspire them to pursue something that they would have never thought of pursuing before. Mikkael Sekeres: I had a very similar experience. It was during fellowship that my very first month of fellowship I was placed on the leukemia service with Rich Stone at Dana-Farber, and I never turned back. He was such a fabulous mentor. I couldn't imagine doing anything else with my career. You write this piece. We loved this piece when you submitted it, myself and the editorial staff. And you write it from the perspective of someone who has recently finished fellowship, which you have. And you write in particular that- this one quote, "During my first year as an attending, I had braced for the steep learning curve, the finality of being the decision maker, the quiet hours at night when treatment decisions still played in my head. What I hadn't prepared for was the weight of uncertainty." It's a great line. So now that you're on the other side of training, what do you think could have prepared you better for the weight of uncertainty? Dr. Sondos Zayed: I had such wonderful mentors throughout my training, and so they were fantastic and I learned so much from them, but sometimes it just took having to be the final decision maker for me not to have to have the security of somebody to just turn back to immediately after a patient encounter, for example, and be like, "Oh, my supervisor can answer this question," or, "Here are my thoughts, but my attending can also join in the discussion," or give their thoughts as well. So that sort of cushion is no longer there. And so when I'm in the room by myself making those decisions with patients, nothing can really prepare you for that. You just have to go in and then do it yourself. Mikkael Sekeres: There is a safety net to training by design and thank God there is, right? Where we can always turn to somebody more experienced than us to answer those hard questions or to know what to do. And that's what's pulled out from under us when we become attendings, when we become the final pathway, when people suddenly turn to us and say, "Okay, what are we going to do here?" or, "What's the answer?" Did anybody during your training model "I don't know"? So did you see your own attendings say "I don't know" to patients and see how that played out? Dr. Sondos Zayed: Not as much, and I think there's a culture in medicine where when people walk into that room, they're hoping that you have all the answers, and you don't want to disappoint them. And so sometimes what we do is we rely on like the evidence and the data and the numbers that are in the literature to answer questions that the patient is asking in an absolute way but we answer it in a probability or a percentage or, "Most likely this will happen," or, "These are the potential, you know, this is the median overall survival," or, "Progression-free survival," or, "This percentage of people have this toxicity," for example. And so it's easy for us to fall back on that cushion of, "These are the numbers and the evidence." And that's what I saw modeled most frequently. But when I started practicing as an attending, what I realized is that when a patient comes in and they sit in front of you, they ask, "How long am I going to live?" What they're asking about is how long they specifically are going to live and not what the median survival in X study is telling us that that's how long they most likely would live, just as an example. And so what I had to do, when I'm speaking to patients, I kind of separate those two concepts where I start with, "I don't know, because I don't have a crystal ball, and your circumstances and how you respond to treatment is something that I can't predict before anything has started. And it's it's just I really don't know. But what I can say is on average in this study, this is what we see, and there's a 95% confidence interval, and most people fall within that." And so I separate their immediate outcome with the data that we have. So that- because sometimes when I say, "Oh, your median survival is one year," they hear, "I'm going to only live for one year." And then you always have these patients that come through and be like, "You know, they told me I only had six months to live, but here I am two years later." And really it is again, we live in a world of probabilities and confidence intervals, but for the patients themselves, this is their life. Mikkael Sekeres: Yeah. One of the aspects of your essay that I really liked is the title, "The Power of 'I Don't Know'" because saying, "I don't know," actually does have some power to it. And I've seen this demonstrated in a couple of different ways. I had a boss once who we'd all be in a meeting, and someone would ask a question, and the boss would say, "I don't know." And he said it in a way where one reaction from other people in the meeting could have been, "Oh, how could he be such an idiot and not know the answer to this?" But what wound up happening is people reacted to it by saying, "Gee, if he doesn't know, then it's okay that I don't know also. And maybe if he doesn't know, that means that maybe I thought I knew, but maybe I really don't know as well as I should." And it makes you kind of redouble your efforts to understand whatever's being communicated in the meeting. So I always thought that there was this power in saying, "I don't know," in meetings, but you bring up the power of "I don't know" in patient interactions. So tell me what is the power in saying, "I don't know," to a patient? What is it that that conveys to a patient and how does that affect the relationship that you have with your patients?
