A guest column by the American College of Physicians, exclusive to KevinMD.com.
In the late 1800s, William Osler stated, “… if you want a profession in which everything is certain, you had better give up medicine.” He made this observation at a time when the science underlying health care was nascent, and little was understood about the effectiveness of treatments available for specific diseases, if they existed. Physicians therefore struggled to put the pieces of what was known into a more comprehensive understanding of the overall care of their patients, knowing that the best they might have to offer was to be present at the bedside and provide support and comfort.
Osler recognized the profound personal challenges faced by physicians in trying to provide care given these limitations, particularly when sick patients turned toward their doctors for answers and a cure. He also observed that discomfort with medical uncertainty was a major factor driving physicians to prescribe ineffective and potentially dangerous interventions in an attempt to help their patients, but that also frequently put them in peril. Paradoxically, in his writings Osler encouraged physicians to recognize the uncertainty inherent in the care of patients and use it to strengthen the therapeutic bond between patient and doctor, avoiding the urge to act based on our discomfort with not having all the answers.
Over 100 years later, we are fortunate to have an overwhelming amount of knowledge about disease and how to effectively treat it. Yet much as physicians in Osler’s time, we continue to struggle with medical uncertainty and it continues to have potentially detrimental effects on both our patients and us as physicians.
There are multiple reasons why we are uncomfortable with medical uncertainty. As humans, we seem to be “hard-wired” to avoid uncertainty in general. It is likely the innate fear of the unknown and the sense of vulnerability it triggers that underlies our quest for certainty in both our personal and professional lives. We are naturally wary of the many “gray” areas of life and are compelled to seek to definitively explain or make sense of them.
Additionally, our medical training does not generally prepare us well to deal with uncertainty. Given the tremendous amount of scientific data that needs to be learned in order to practice medicine, our education tends to focus on organizing this information with the goal of being able to achieve specific diagnoses to guide treatment. While this is a critical function of being a physician and one that provides an immense amount of intellectual satisfaction in “solving” patient problems, it may also leave us less equipped to deal with the “grayscale” world of medicine in which not all answers are clear, and perhaps more importantly, may impair our ability to apply the judgment and prudence needed in bringing this scientific knowledge to bear in the care of patients.
And the culture of medicine that existed in Osler’s time continues today. Physicians tend to be uncomfortable in admitting uncertainty either to themselves or their patients. An incomplete understanding a patient’s situation may trigger a sense of professional incompetence, contributing to a universal sense of inadequacy or what is better known as the “imposter syndrome.”
And, as in Osler’s time, some feel that expressing uncertainty to patients may expose a lack of knowledge, skill, or expertise to those who are looking toward them for definitive answers.
But there are significant potential negative consequences associated with our discomfort with medical uncertainty and our efforts aimed at moderating it.
It may result in the excessive ordering of interventions that if not injurious or costly themselves may lead to a cascade of additional investigation to seek further confirmation of a diagnosis or assess incidental findings generated by testing. It may also lead to overuse of referrals to affirm or confirm our clinical suspicions. And by attempting to achieve a sense of certainty too soon, we risk inhibiting the evolution of the diagnostic process which needs to be quite fluid in patients with multiple problems, increasing the risk of diagnostic error. Taking an “algorithmic” approach toward patient care in which each issue or problem is evaluated and treated in isolation without consideration of the interrelatedness of a person’s problems, individual circumstances, or patient values leads frequently leads to suboptimal, inefficient, and fragmented patient care.
On a personal level, our response to the uncertainty integral to patient care can contribute to work-related stress and the accelerated rates of burnout among physicians. It may also decrease our own perceived self-worth as clinicians when we don’t feel as though we are able to fully exercise the judgment and wisdom we have accumulated over time. And it may influence career choice as people less prepared to deal with medical uncertainty may gravitate toward clinical areas where the focus of patient care may be more narrowly defined and perceived as being more manageable.
So how do we deal constructively with medical uncertainty in an era when patients are getting older and more complex with multiple concurrent and interrelated medical issues, requiring that we make clinical decisions based on imperfect data and knowledge?
As it is no longer possible for a single physician to have adequate knowledge to manage all of the problems afflicting most of their patients, attempting to master each and every issue is not the answer, either through personal expertise or seeking the input of others. Rather, essential to addressing medical uncertainty is an adequate understanding of disease and its natural course to be able to manage our patients’ complexity in a meaningful way. This means knowing our patients and their unique disorders well enough to know when immediate intervention or the expertise of others is required and when there is room for the individualized, iterative process of diagnosis and treatment to unfold in those situations where things are less clear. It also requires that we develop confidence in our own clinical skills and judgment to help guide and coordinate the care of our patients and to serve as a bridge between the science we know and the complexity of disease in our patients that may be less defined.
We must also accept that not knowing everything is neither a sign of personal inadequacy nor a source of shame. Moving away from the personal emotional discomfort that uncertainty triggers toward seeing it as a surmountable and engaging intellectual challenge based on the curiosity about the unknown that we are well-prepared to handle can reinvigorate our sense of worth and satisfaction as physicians.
Plus, we must learn how to constructively communicate medical uncertainty to our patients. Not only is this essential to patients truly engaging in shared decision making, but partnering with them around the uncertainties in their care can serve as the basis for stronger and more meaningful patient-doctor relationships.
True wisdom and expertise result from our embracing medical uncertainty in a profession in which uncertainty is the norm.
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