“Medicine is a science of uncertainty and an art of probability”
-Sir William Osler
There were many people who were saddened at the passing of Alex Trebek. My family was no exception. My parents and I would watch “Jeopardy!” At 6 pm, yelling out answers while eating dinner. Without fail we would yell at the players to bet it all on the Daily Double; my mom and dad would marvel at how I could miss most of the questions in the History section and yet run the category on Potent Potables. Decades later, I still watch it with my family. And I always feel a little bad when I miss a question.
Alex’s fellow Canadian Dr. Osler, one of the founders of Johns Hopkins Hospital and a renowned diagnostician, probably would have rocked “Jeopardy!”. Interesting, given his quote above. Are we, as a profession, comfortable with being uncertain?
“Tolerating Uncertainty- the Next Medical Revolution?” , link below, was published in the NEJM in 2016. It’s only two pages and totally worth the read.
https://areasoci.sirm.org/uploads/Documenti/SDS/828b6893d23b878ccb2be267ac322d6a1c91085c.pdf
It really doesn’t even question whether or not we as medical professionals are comfortable with uncertainty. It just assumes we aren’t. We are constantly presented during the educational process with messsages that we are either “right” or “stupid”.
Uncertainty=ignorance
In our minds, the path to success begins with the correct answer. Anything else is unacceptable. The jump to a diagnosis to just to get to an answer may be just as problematic, as we may miss key information or exercise cognitive bias for no other reason than we want to push that button and get our Daily Double correct.
Trying to achieve a sense of certainty too quickly
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| < cognitive bias
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Premature closure of the decision making process.
Ok. So how to make this process change? The authors suggest that the first thing to do is to not equate uncertainty with a lack of knowledge or being bad at what we do. Uncertainty is not the final destination. It’s a rest stop. If uncertainty is the rest stop, then what’s the car we drive to get there?
Tolerance of uncertainty ——> CURIOSITY
Wanting to know the answer, being transparent about not knowing the answer and committing to the patient that we truly desire to get to it for their benefit. Maybe that’s why the authors equate a decreasing ability to tolerate being uncertain with an increased risk of burnout. The pressure to be “right” all the time is not realistic.
I teach martial arts in my spare time (it’s therapy for me. Anti-burnout meds. And to spar kids half my age and not get beat up bolsters my ego) and we traditionally ask students questions at belt rank exams about martial arts history, techniques, etc. We do our best as instructors to teach students the information they need for this, but of course sometimes they freeze up at testing. So we teach them one simple phrase if they forget.
“I don’t know, but I will find out”.
We teach them that that is a perfectly acceptable answer. AND IT IS. We are not taught to do this in medical school or residency. And we don’t realize that, when we say this to our patient, because we really don’t know and we need to take more history, do another physical, do more research, maybe do another test, that the patient is absolutely fine with it. In my experience, patients are much more likely to have a collaborative relationship with a physician who honestly expresses his or her humanity.
It’s not about right or wrong. Maybe the best bit of evidence that lets us know that’s it is ok ?
I want to be a Jedi. 🙂
Next up. Is there a way to assess our natural tolerance of uncertainty?
Thanks for reading. Peace.