Tolerating Uncertainty — The Next Medical Revolution? N Engl J Med, Nov 2016
Our quest for certainty is central to human psychology, however, and it both guides and misguides us.
Although physicians are rationally aware when uncertainty exists, the culture of medicine evinces a deep-rooted unwillingness to acknowledge and embrace it.
Embodied in our teaching, our case-based learning curricula, and our research is the notion that we must unify a constellation of signs, symptoms, and test results into a solution.
We demand a differential diagnosis after being presented with few facts and exhort our trainees to “put your money down” on a solution to the problem at hand despite the powerful effect of cognitive biases under these conditions
Too often, we focus on transforming a patient’s gray-scale narrative into a black-and-white diagnosis that can be neatly categorized and labeled
The unintended consequence — an obsession with finding the right answer, at the risk of oversimplifying the richly iterative and evolutionary nature of clinical reasoning — is the very antithesis of humanistic, individualized patient-centered care.
The CDC has stepped right into this trap with its scientifically foolish standard guidelines for prescribing.
Instead of tailoring prescriptions to individuals, they assume, a patient’s pain sensation can be converted into some “standard problem” to be “fixed” with “standard solutions”
We believe that a shift toward the acknowledgment and acceptance of uncertainty is essential — for us as physicians, for our patients, and for our health care system as a whole. Only if such a revolution occurs will we thrive in the coming medical era.
In medicine today, uncertainty is generally suppressed and ignored, consciously and subconsciously.
Unmeasurable, and sometimes even undetectable, pain itself is the embodiment of uncertainty.
Doctors are no longer allowed to treat our pain as an aspect of our unique being.
Instead, they are forced to:
- disregard their experience and training,
- ignore individual differences, and
- adhere to some bureaucrat’s idea of “standard practice”,
Its suppression makes intuitive sense: being uncertain instills a sense of vulnerability in us — a sense of fear about what lies ahead
Our protocols and checklists emphasize the black-and-white aspects of medicine
Yet the reality is that doctors continually have to make decisions on the basis of imperfect data and limited knowledge, which leads to diagnostic uncertainty, coupled with the uncertainty that arises from unpredictable patient responses to treatment and from health care outcomes that are far from binary.
Great tensions are created by the conflict between the quest for certainty and the reality of uncertainty.
Physicians’ difficulty in accepting uncertainty has also been associated with detrimental effects on patients, including excessive ordering of tests that carry risks of false positive results or iatrogenic injury and withholding of information from patients
In addition, by attempting to achieve a sense of certainty too soon, we risk premature closure in our decision-making process, thereby allowing our hidden assumptions and unconscious biases to have more weight than they should, with increased potential for diagnostic error.
In our experience, many current medical students, the digital natives, seek structure, efficiency, and predictability; they insist on knowing “the right answer” and are frustrated when one cannot be supplied. This attitude no doubt increases the likelihood that they will perceive uncertainty as a threat.
We believe that cultivating a tolerance of uncertainty, and addressing the barriers to this goal for physicians, patients, and the health care system, will require a revolutionary change in medicine’s cultural attitude and approach to uncertainty.
Our curricula should recognize diagnosis as dynamic and evolving — an iterative process that accounts for multiple, changing perspectives.
We can speak about “hypotheses” rather than “diagnoses,” thereby changing the expectations of both patients and physicians and facilitating a shift in culture
As we move further into the 21st century, it seems clear that technology will perform the routine tasks of medicine for which algorithms can be developed.
Our value as physicians will lie in the gray-scale space, where we will have to support patients who are living with uncertainty — work that is essential to strong and meaningful doctor–patient relationships
It is therefore critical that we focus on thriving in this space and changing our professional culture to allow for uncertainty.
Only uncertainty is a sure thing.
Certainty is an illusion.