You are not a SHOEMAKER. St.Emlyn’s

-Jacques-Albert Senave-Apelles the


Simon recently claimed his new favourite word is pleiotropic, and whilst I don’t want to get into a vocab competition, I offer my own new favourite word: ultracrepidarianism. This is something I am eternally fearful of, but in all likelihood am probably guilty of daily; giving opinions and advice on matters outside of my own knowledge. The origin of the term comes from Pliny the Elder and in Latin states ‘Sutor, ne ultra crepidam’ meaning ‘shoemaker, not above the sandal’. It is alleged to have been uttered after a shoemaker criticised an artist’s work (as depicted above). As a trainee in emergency medicine it often feels as though there is a constant effort to try so very hard to not to come across as the shoemaker did.

The current training programme encourages trainees to reflect on our practice and identify our shortcomings and areas for improvement. Writing prosaic reflections on patient interactions is valuable, and I dare not dispute that. However as part of my reflective practice I like to read. I particularly like to read non-fiction and particularly literature about areas outside of medicine. Having just finished reading ‘Think Like a Freak…  How to Think Smarter About Almost Everything‘, by Stephen Dubner and Steven Levitt, I felt inspired to share some lessons I took and how I will apply them to my work. The authors are an economist and a journalist who seek alternative solutions to a diverse selection of problems.


The book argues that the hardest three words to say in the English language are ‘I don’t know’. People don’t want to look silly, incompetent or stupid by admitting when they don’t know something. This is something that we are all guilty of and happens far too frequently. As someone who is on the lower rungs of the career ladder I probably get asked more questions that I don’t know the answer to than those at the top. I would argue that it is important for those at any point of their career to say ‘I don’t know’. Please don’t take this to be advocacy of not trying to work an answer out or not attempting to think of possible answers. There is a caveat; if you are going to say ‘I don’t know’ it comes with a fee, which is that you go and work hard to find out the answer. There is no shame in not knowing everything. Saying these three words can be an empowering first step to increasing your knowledge. I have respect for those that can admit what they don’t know and then go and find out the answer, so much more than for those who ramble and produce some nonsensical answer to try and save face.

Problem Solving…

The authors make some interesting points about problem solving, that aren’t framed in the context of the medical profession but are readily transferable. Here is what I took as some key points:

Think like an 8-year-old: An 8-year-old has very few preconceptions and is limitlessly curious. If you take that point of view, you can view everything with excitement and wonderment. 8-year-olds ask silly questions and are hungry for knowledge. Thinking like an 8-year-old may help you ask questions that no one has asked

before, no matter how stupid you might feel it is. Essentially don’t be afraid of the obvious.

Ignore the noisy part of a problem: This is the distracting injury, or the screaming patient when you are triaging. Don’t let it suck you in. Obviously some noisy parts of a problem like significant haemorrhage do need your attention, but sometimes it is easy to get absorbed by a problem and you become fixated. Take a break and look at the detail. This is why we add ‘don’t’ ever forget glucose’ to our ABCD algorithm; so that we don’t forget the little things that have a big impact. Define / redefine your problem; say out loud where you are up to and what the problems are.

Question differently; look for answers in different places: If things are not working out and you can’t work out why, change your tack. Stop, and think laterally. Don’t plough on without thinking about the problem. Approaching a problem from a different angle will produce different results. Don’t just do things because they’ve always been done a certain way. Think different; be different.

Think small: The authors discuss that when tackling a problem we should think small.  Looking at it this way makes a real difference; trying to tackle a big problem off the bat can be an exercise in futility. Smaller problems are naturally more manageable. . Small questions are not asked as frequently as big questions and therefore are sometimes a new area for learning. Think small, take small problems and solve them.  Imagine when you are dealing with a patient with complex social and medical issues; you might not always be able to answer all their problems, but if you break it down into smaller problems you might be able to reach a solution.

Feedback is key: Dubner and Levitt argue that the simpler the task the easier it is to get feedback and likewise, the harder a task, the harder it is to get good feedback. We should be aware of this. It is difficult to give feedback on complex and challenging tasks, yet we must strive to do so. For us in the medical profession, feedback is essential. We get feedback (if we look for it) from every patient interaction; every procedure we do; every diagnosis we make. As trainees we get feedback in the form of work-based assessments.  It is important to focus on a small part of a clinical encounter if you are to give truly useful feedback.  It is difficult to give feedback on an entire clinical interaction; there are just too many components to mentally attend to.


As primarily a book on economics (of sorts) the authors talk about incentives. Incentives are used everywhere and influence so much of our behaviour. Whilst I won’t go into incentives in the ED now, I just hope for you to ponder on the place incentives have in Emergency Medicine. I believe that they could be used to reduce attendances, increase patient satisfaction and draw more people to the specialty (in the UK); but that is just my opinion.

I wholeheartedly recommend reading any (and all) of the books in the ‘Freakonomics’ series. They really are enlightening and I for one am confident they will influence my approach to work…and life in general. Check out the Freakonomics blog here as well.

You are not a shoemakerThink smallThink


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Cite this article as: Richard Carden, "You are not a SHOEMAKER. St.Emlyn’s," in St.Emlyn's, January 22, 2015,

11 thoughts on “You are not a SHOEMAKER. St.Emlyn’s”

  1. Really interesting read. Wonder whether the nature of EM makes ultracrepidarianism (love it!) more likely – there is so much that we need to know about (anything and everything) that it is very difficult to admit to a knowledge deficit. Whereas a super-specialist may find it easier to admit that something is out of their field. Its reminded me that we need to constantly be aware that there may be another, better way that we don’t know about (yet) and be humble enough to constantly challenge our beliefs as we go through our careers.

    1. Thanks Sarah, I’m glad you enjoyed reading the post. I absolutely agree that ultracrepidarianism is rife in EM just by virtue of the nature of the job. I couldn’t possibly agree more that we should be humble and we should maintain an insatiable hunger for new knowledge!

  2. roberto cosentini

    Great point Rich!
    I suspect that in the ED much of our diagnostic efforts end up with these three simple words…
    Our major issue is to exclude serious causes of common chief complains, such as chest pain, headache, syncope etc.
    ‘I don’t know’ should be the honest answer to the worried patient who’s asking ‘what’s wrong with me’ after a negative ED workup.
    As suggested by Simon in your great podcast on chest pain, we should be humble to admit we don’t know the exact cause, and tell our patients that if they will feel something wrong we’ll be more than happy to help them again.

  3. thanks rich. great food for thought.

    particularly like your points about (i) focussing on a small part of an interaction in giving feedback – will use when debriefing – and (ii) thinking small when trying to conceptualise a solution to a problem – will try and use for planning in situ sim (which seems like a big problem for me at the minute!)

    on a more general note – i had an insight into the tension around ultracrepidarianism just this week..

    an unstable patient with variceal bleeding in resus – one needing emergent rather than urgent gastroscopy, as in NOW.

    i was in the uncomfortable position of being a go-between, between my ED consultant, who correctly wanted to prepare for possibly needing to tube the patient in resus, and asked me to get stuff ready to do so; and the airway specialists, who turned up as we were doing so, and whose faces made it clear they thought we were idiots for considering tubing outside of theatre.

    i felt like a wally but also felt backed into a corner, and so of course defended my position even though i knew we wouldn’t actually want to tube there and then, for the pt’s haemodynamic sake.

    countless other examples of feeling constantly at the edge of my own “expertise” from the same pt – how many times have i prescribed or used terlipressin and worrying about the potential side effects – do i even know what a S-B tube looks like let alone put it in – etc…. and having to strike a careful balance between “i don’t know” and using what knowledge i have to make a decision and enact it.



  4. Interesting thoughts Rich, thanks. A counterpoint – one of the strengths of our specialty is that we are (generally) better than many at managing uncertainty. So you need to distinguish when a) something is unknown to you – in which case ask/find out/admit it OR b) just plain unknown – in which case, cope with that and get on with looking after the patient!

    …..and then obviously make sure RB or SC initiates some research about it 😉

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