Communicating honestly with patients about uncertainty

When looking at the way medical education and patient care is delivered, there is no question that there is a culture of “knowing.” From the moment a pre-med enters high school, they are bombarded with tests that assess knowledge. This extends throughout medical training, where the development of an assessment and plan in residency is paramount in the transition to an attending physician who must make autonomous decisions for their patients.

But do we always have to have an answer?

I have realized there are only two times in your medical career you will often hear a medical practitioner say “I don’t know,” although the consequences of doing so at either of these stages are drastically different.

The first is as a medical student. A very widely acknowledged rule amongst medical students is that you never want to say those three words even though often you may be thinking it. Acknowledging a lack of understanding at this stage suggests an inability to engage in critical thinking to produce a thoughtful differential diagnosis and plan. Secondarily, this is thought of as one of the few times you are “allowed to be wrong” no matter what you say, although any student can tell you that this is not necessarily true as your evaluation often reflects how often you are correct. It makes sense to have to come up with an answer at this stage as not having an answer means you haven’t really thought about the information you have collected in a productive way and would otherwise merely be parroting information.

The second time I find I hear “I don’t know” is when working with senior practitioners, generally with many years of practice under their belt or on the cusp of retirement. This statement in this instance, is said in wisdom. Having a career’s worth of assessments and plans has shown them that there is no current evidence-based answer for the problem in front of them, and a large sample size of that specific archetype of patient that has not benefited from treatments has demonstrated that it is not cost-effective or judicious to pursue further treatments.

Another potential reason for this phrase in the latter group may relate to a greater sense of freedom from patient expectations, which, in addition to how doctors are educated, is a large part of why practitioners feel pressured to provide an answer in ambiguous circumstances. These expectations are evident when Googling physicians. Often times you can see one-star reviews, claiming “Dr. X did nothing for me” and “Dr. Y made me wait 45 minutes to tell me that he couldn’t help me.” We live in an era of commodified medicine; ergo, the practitioner must supply a service for the “consumer’s” time or else suffer repercussions in a digital age. More experienced physicians often experience immunity from this, as they have generally had time to develop a patient base which was largely formed prior to the internet age, and have developed a longstanding rapport with patients.

Another interesting thought is that perhaps there is not enough time in interactions to justify saying, “I don’t know.” It is rare that a doctor is able to spend ample time with their patient getting to know them, conducting a full history and physical exam, and utilizing time to explain why they don’t know the answer to a problem.  This time for communication is instrumental on the patient’s end. Many patients have been struggling with a medical problem on the order of days to years, have been waiting for a block of time to set up an appointment with their physician, and have been sitting in the waiting area often for a long time. Looking through their eyes, when they were seen, most of the information was collected by a medical student or resident physician in a quick slot of time. Often times, it may appear like their provider did not take time to hear their concerns to come up with a thoughtful assessment and may be saying they do not know either from a lack of understanding or an inability to listen to their concerns. Many older practitioners often manage to get more out of their time, being able to display the advanced levels of communication necessary to distill higher order thinking and structure it into a condensed time frame.

Wisdom is also assumed with age, and reputations often precede physicians.  As one becomes more senior in practice, it is evident that the patient tends to trust a lack of an answer more, as there is an assumption that if the physician in front of them does not know the answer, no one else will. The person in front of them oftentimes is the “second opinion” they wanted to get after the first practitioner.

This is not to say there are not medical practitioners of all stages who are comfortable with communicating uncertainty, but simply my observations based on a decade working with numerous physicians. I would also like to hear reader thoughts regarding this topic. In the long run, unnecessary referrals or management cost the patient time and finances, and it is interesting to explore the repercussions of not having an answer in medicine. It is human to want to provide a sense of hope for others, although there are benefits and costs associated with doing so and complex systematic factors within the health care system involved.

Kunal Shetty is a medical student.

Image credit: Shutterstock.com

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