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PE R S PE C T IV E Tolerating Uncertainty

Tolerating Uncertainty

Becoming a Physician

Tolerating Uncertainty The Next Medical Revolution?


ArabellaL. Simpkin, B.M., B.Ch., M.M.Sc, and RichardM. Schwartzstein, M.D.

A
t once it struck me what
quality went to form a Man
of Achievement...when a man
iterative and evolutionary nature
of clinical reasoning is the
very antithesis of humanistic, in-
seem, intuitively, to be a toler-
ance for uncertainty and a curi-
osity about the unknown. Have
is capable of being in uncertain- dividualized patient-centered care. we created a culture that ignores
ties, mysteries, doubts, without We believe that a shift toward and denies that requirement?
any irritable reaching after fact the acknowledgment and accep- Could our intolerance of uncer-
and reason. tance of uncertainty is essential tainty, in turn, be contributing to
John Keats, December 18171 for us as physicians, for our the accelerating rates of burnout
patients, and for our health care and the rising cost of health
These words penned by John system as a whole. Only if such a care? For there is no doubt that
Keats, who was a physician as revolution occurs will we thrive absolute truth and certainty are
well as a poet, remind us of the in the coming medical era. hard to come by in clinical med-
human struggle to live in a gray- In medicine today, uncertainty icine.
scale space where uncertainty is is generally suppressed and ig- Great tensions are created by
rife a space that is neither nored, consciously and subcon- the conflict between the quest for
black nor white. Our quest for sciously. Its suppression makes
certainty is central to human intuitive sense: being uncertain
psychology, however, and it both instills a sense of vulnerability in
guides and misguides us. us a sense of fear about what
Although physicians are ratio- lies ahead. It is unsettling and
nally aware when uncertainty makes us crave black-and-white
exists, the culture of medicine zones, to escape this gray-scale
evinces a deep-rooted unwilling- space. Our protocols and check-
ness to acknowledge and embrace lists emphasize the black-and-
it. Embodied in our teaching, our white aspects of medicine. Doc-
case-based learning curricula, and tors often fear that by expressing
our research is the notion that uncertainty, they will project
we must unify a constellation of ignorance to patients and col-

signs, symptoms, and test results leagues, so they internalize and
into a solution. We demand a mask it. We are still strongly in-
differential diagnosis after being fluenced by a rationalist tradition
presented with few facts and ex- that seeks to provide a world of
hort our trainees to put your apparent security.
money down on a solution to Yet the reality is that doctors
the problem at hand despite the continually have to make deci-
powerful effect of cognitive biases sions on the basis of imperfect certainty and the reality of un-
under these conditions. Too often, data and limited knowledge, certainty. Doctors maladaptive re-
we focus on transforming a pa- which leads to diagnostic uncer- sponses to uncertainty are known
tients gray-scale narrative into tainty, coupled with the uncer- to contribute to work-related
a black-and-white diagnosis that tainty that arises from unpre- stress.2 Physicians difficulty in
can be neatly categorized and dictable patient responses to accepting uncertainty has also
labeled. The unintended conse- treatment and from health care been associated with detrimental
quence an obsession with outcomes that are far from bi- effects on patients, including ex-
finding the right answer, at the nary. Key elements for survival cessive ordering of tests that carry
risk of oversimplifying the richly in the medical profession would risks of false positive results or

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PERS PE C T IV E Tolerating Uncertainty

iatrogenic injury and withhold- need to thrive in 21st-century tivity in the illness narrative, diag-
ing of information from patients.3 medicine. nostic sensitivity and specificity,
In addition, by attempting to We believe that cultivating a unpredictability of treatment out-
achieve a sense of certainty too tolerance of uncertainty, and ad- comes, and our own hidden as-
soon, we risk premature closure dressing the barriers to this goal sumptions and unconscious bias-
in our decision-making process, for physicians, patients, and the es, to name a few. We can then
thereby allowing our hidden as- health care system, will require a teach physicians specifically how
sumptions and unconscious biases revolutionary change in medicines to communicate scientific uncer-
to have more weight than they cultural attitude and approach to tainty, which is essential if pa-
should, with increased potential uncertainty. Our curricula (for- tients are to truly share in deci-
for diagnostic error. mal, informal, and hidden), as- sion making, and we can reduce
Our need to tolerate uncertain- sessments, and evaluations will everyones discomfort by refram-
ty has never been more urgent. need to be modified to empha- ing uncertainty as a surmount-
Technology is advancing at light- size reasoning, the possibility of able challenge rather than as a
ning speed, and we are now able, more than one right answer, and threat.
In keeping with these curricu-
lar goals, our assessments of stu-
We can speak about hypotheses dents can reflect the gray-scale
environment, shifting away from
rather than diagnoses, thereby changing the black-and-white multiple-
the expectations of both patients and choice questions that are all too
common in our exams and that
physicians and facilitating a shift in culture. inculcate in students the belief
that there is always a right an-
swer. We need to focus on evalu-
at the touch of a button, to get consideration of our patients ating clinical reasoning and the
instant access to a plethora of values. Educators can start by demonstration of tolerance for
services and products. In our ex- asking questions that focus on uncertainty.
perience, many current medical how and why, not what As we move further into the
students, the digital natives, seek stimulating discussion that em- 21st century, it seems clear that
structure, efficiency, and predict- braces the gray-scale aspects of technology will perform the rou-
ability; they insist on knowing human health and illness, aspects tine tasks of medicine for which
the right answer and are frus- that cannot be neatly catego- algorithms can be developed. Our
trated when one cannot be sup- rized, and encouraging students value as physicians will lie in the
plied. This attitude no doubt in- curiosity to explore and capacity gray-scale space, where we will
creases the likelihood that they to sit comfortably with uncer- have to support patients who are
will perceive uncertainty as a tainty, acknowledging that cer- living with uncertainty work
threat. Given the growth of ac- tainty is not always the end goal. that is essential to strong and
cess to information online and Our curricula should recog- meaningful doctorpatient rela-
electronically, students can spend nize diagnosis as dynamic and tionships. It is therefore critical
less time at the bedside in the evolving an iterative process that we focus on thriving in this
gray-scale world of medicine and that accounts for multiple, chang- space and changing our profes-
more time in front of a screen ing perspectives. We can speak sional culture to allow for uncer-
absorbing processed and general about hypotheses rather than tainty. As faculty, we will have to
information rather than immedi- diagnoses, thereby changing the model for our students the prac-
ate and idiosyncratic realities. expectations of both patients and tice of medicine in which it is all
Their online experience may re- physicians and facilitating a shift right to be uncertain perhaps
inforce their sense of a black- in culture. This shift may entail reminding ourselves of Oslers
and-white world where certainty discussing uncertainty directly maxim that medicine is a sci-
is readily achievable the antith- with patients, intentionally re- ence of uncertainty and an art of
esis of the perspective they will flecting on its origins subjec- probability.4 Ironically, only un-

1714 n engl j med 375;18 nejm.org November 3, 2016

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Copyright 2016 Massachusetts Medical Society. All rights reserved.
PE R S PE C T IV E Tolerating Uncertainty

certainty is a sure thing. Certain- R.M.S.), and the Division of Pulmonary, costs of health care. Lancet 1996;347:595-
Critical Care, and Sleep Medicine, Beth Is 8.
ty is an illusion. rael Deaconess Medical Center (R.M.S.) 3. Kassirer JP. Our stubborn quest for diag-
Disclosure forms provided by the authors all in Boston. nostic certainty: a cause of excessive testing.
are available with the full text of this article N Engl J Med 1989;320:1489-91.
at NEJM.org. 1. Forman MB. The letters of John Keats. 4. Bean RB, Bean WB. Sir William Osler:
Oxford, United Kingdom:Oxford University aphorisms from his bedside teachings and
From the Division of General Internal Med Press, 1931. writings. New York:Henry Schuman, 1950.
icine, Massachusetts General Hospital 2. Logan RL, Scott PJ. Uncertainty in clin- DOI: 10.1056/NEJMp1606402
(A.L.S.), Harvard Medical School (A.L.S., ical practice: implications for quality and Copyright 2016 Massachusetts Medical Society.
Tolerating Uncertainty

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The New England Journal of Medicine
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Copyright 2016 Massachusetts Medical Society. All rights reserved.