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Uncertainty
In my forty plus years of practice, I have long-since learned that in medicine there are only great questions, not great answers. That does not mean there is nothing to be done, but it does mean that what we do must be accepted as having uncertainty both as to best choices and to outcomes. Thus, it was a bit of a surprise to read an editorial in The New England Journal of Medicine titled “Tolerating Uncertainty—The Next Medical Revolution?”[1] Their premise is that physicians are rationally aware of uncertainty, but “the culture of medicine evinces a deep-rooted unwillingness to acknowledge and embrace it…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.” In their discussion, the authors point out this issue is not simply a philosophical concern. “Great tensions are created by the conflict between the quest for certainty and the reality of uncertainty. Doctors’ maladaptive responses to uncertainty are known to contribute to work-related stress. Physicians’ difficulty 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.” From their vantage point in academia, they note the new generation of “digital-native” medical students seem frustrated and upset when the technology does not provide definitive answers to the questions they ask. They suggest we need to change our language to help arm students to deal with uncertainty. I am not sure language is the problem, so much as the need for experienced clinicians to pass on the hard-won experience that uncertainty has been and always will be with us. Sir William Osler famously stated the problem thusly. “Medicine is a science of uncertainty and an art of probability.” Somewhere years ago I saw this paraphrased as: “The practice of medicine is making adequate decisions on the basis of inadequate data.” I suspect the complaint about students seeking the “right” answer is not a function of digital technology, but a desire every generation brings to wanting to “do the right thing.” Most people pursue medical education to be able to help people by diagnosis and treating their ailments and helping them to live better. While our ability to do so has improved dramatically in my 46 years since starting medical school, so too has our ability to hurt patients. Perhaps this is more evident to the medical young than it was to us, hence driving their desire to be sure they are doing the right thing. On the other hand, it is clear that a lot of physician behaviors are driven by their reaction to the problem of uncertainty and their desire to help, not harm. Self-destructive behavior and chemical dependency are prevalent. In the past they were handled behind closed doors , but these issues are now being confronted, at least in Tennessee, by a therapeutic approach designed to return the physician to his/her previous functions. While the approach does not always work, it has made clear the scope of the problem. As noted, test and procedure ordering behaviors are driven by uncertainty as well. In today’s context, this can also mean “checking the boxes” behaviors. I recently saw one of my long-term patients who was wearing a life vest and 30 day event monitor after cardiac syncope in the setting of systolic heart failure. He is being evaluated for an implantable defibrillator/pacemaker. He also has diabetes related to his transplant rejection medication, and his A1c was greater than 10. In the context, I did not see much point in complicating his life lecturing him about the value of using more insulin, since he started the visit by saying “I’m falling apart.” Indeed he is, but I felt a twinge about not checking the box, even though I did not think it mattered to him. While I am set in my ways, this episode made me realize the younger doctor would have retreated to giving the talk and moving on. He/she might not have visited with him about the travails he has dealt with in the past 25 years of our association. I think this conversation was more therapeutic for him than getting his A1c closer to goal. While some tension on these issues is inevitable, I have seen several good physicians drive themselves into early retirement because of the anxiety associated with uncertainty. The authors conclude with a prediction, which I agree with completely, and have addressed in other ways in these articles. “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.” Maybe “Star Trek” had it right. Dr. “Bones” McCoy had a device that made all the diagnoses and did the treatments. His job was to be the ultimate humanist who helped the patient understand what the device was telling him. 20 November 2016 [1] Simpkin AL, Schwartzstein RM. Tolerating Uncertainty—The Next Medical Revolution? N Engl J Med 2016;375:1713-1715. doi.10.1056/NEJMp1606402. |
Further Reading
Are We Too Task Oriented? The number of tasks doctors must complete grows exponentially. Have we become too task oriented at the expense of our patients? Medical Evidence Medical evidence is a four-source: guidelines, registries, data mining and " in my experience". Different clinical situations use different types of evidence and have different implications for provider behavior. These implications are considered in detail. More on Biases A recent series of articles in the New England Journal of Medicine provide more insight into the issue of bias in medical decision making. On Dying in America The IOM report "On Dying in America" makes recommendations for change that physicians should embrace. The One Best Way |