“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.”¹

This is the introduction to a recent article in the New England Journal of Medicine that criticises the emphasis in modern medical practice on establishing a definite diagnosis through extensive investigation in all cases. We fear that admitting uncertainty will demonstrate vulnerability and lack of knowledge when we are expected to show confidence and strength.

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 unpredictable patient responses to treatment and from healthcare outcomes that are rarely total cure or total lack of effect. What is referred to as ‘senior clinical decision making’ is often the formulation of an action plan that is based on insufficient hard data and is as much a pragmatic ‘best guess’ as an evidence-based strategy.

Doctors must learn to live with uncertainty for their own benefit, as well as that of their patients. The authors point out that maladaptive responses to uncertainty are known to contribute to work-related stress. “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.”¹

Is it possible to prepare future doctors in the management of uncertainty? Medical curricula, assessments, and evaluations will need to be modified to emphasise reasoning, the possibility of more than one right answer and consideration of patients’ values. The NEJM’s suggestion is that “Educators can start by asking questions that focus on ‘how’ and ‘why’ not ‘what’, stimulating discussion that embraces the greyscale aspects of human health and illness, aspects that cannot be neatly categorised, and encouraging students’ curiosity to explore and capacity to sit comfortably with uncertainty, acknowledging that certainty is not always the end goal.”¹

Finally, we must appreciate the uncertainty that patients face when diagnosed with chronic or degenerative disease. Much disability is caused by fear of loss of function and independence as disease and ageing progress. So the emphasis has to shift from cure to management of disease so that impact on quality of life is as little as possible for as long as possible.

Reference

1. Simpkin AL, Schwartzstein RM. Tolerating uncertainty – the next medical revolution? N Engl J Med 2016(Nov 3); 375:1713-1715